Provider Demographics
NPI:1124567110
Name:MINTHORNE, JIMMY JOSEPH (AMFT)
Entity Type:Individual
Prefix:
First Name:JIMMY
Middle Name:JOSEPH
Last Name:MINTHORNE
Suffix:
Gender:M
Credentials:AMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 4823
Mailing Address - Street 2:
Mailing Address - City:RANCHO CUCAMONGA
Mailing Address - State:CA
Mailing Address - Zip Code:91729-4823
Mailing Address - Country:US
Mailing Address - Phone:626-701-4737
Mailing Address - Fax:
Practice Address - Street 1:11721 TELEGRAPH RD
Practice Address - Street 2:
Practice Address - City:SANTA FE SPRINGS
Practice Address - State:CA
Practice Address - Zip Code:90670-3674
Practice Address - Country:US
Practice Address - Phone:562-949-8455
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-02-23
Last Update Date:2023-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAAMFT123444106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist