Provider Demographics
NPI:1013592401
Name:TRAN, JIMMY
Entity Type:Individual
Prefix:
First Name:JIMMY
Middle Name:
Last Name:TRAN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3255 OLD CONEJO RD STE 202
Mailing Address - Street 2:
Mailing Address - City:THOUSAND OAKS
Mailing Address - State:CA
Mailing Address - Zip Code:91320-2153
Mailing Address - Country:US
Mailing Address - Phone:805-254-6249
Mailing Address - Fax:805-568-2494
Practice Address - Street 1:3255 OLD CONEJO RD STE 202
Practice Address - Street 2:
Practice Address - City:THOUSAND OAKS
Practice Address - State:CA
Practice Address - Zip Code:91320-2153
Practice Address - Country:US
Practice Address - Phone:805-254-6249
Practice Address - Fax:805-568-2494
Is Sole Proprietor?:No
Enumeration Date:2021-03-16
Last Update Date:2021-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA19102247106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician