Provider Demographics
NPI:1104377308
Name:HERRON, JIMMIE (CADC-CAS)
Entity Type:Individual
Prefix:
First Name:JIMMIE
Middle Name:
Last Name:HERRON
Suffix:
Gender:M
Credentials:CADC-CAS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:29452 ROCK POINT DR
Mailing Address - Street 2:
Mailing Address - City:LAKE ELSINORE
Mailing Address - State:CA
Mailing Address - Zip Code:92530-7272
Mailing Address - Country:US
Mailing Address - Phone:323-315-2742
Mailing Address - Fax:
Practice Address - Street 1:29452 ROCK POINT DR
Practice Address - Street 2:
Practice Address - City:LAKE ELSINORE
Practice Address - State:CA
Practice Address - Zip Code:92530-7272
Practice Address - Country:US
Practice Address - Phone:323-315-2742
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-10-23
Last Update Date:2016-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAC038500816101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)