Provider Demographics
NPI:1174019863
Name:JIMENEZ, FIDEL JR (SUD COUNSELOR)
Entity Type:Individual
Prefix:
First Name:FIDEL
Middle Name:
Last Name:JIMENEZ
Suffix:JR
Gender:M
Credentials:SUD COUNSELOR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:550 W VISTA WAY STE 202
Mailing Address - Street 2:
Mailing Address - City:VISTA
Mailing Address - State:CA
Mailing Address - Zip Code:92083-5736
Mailing Address - Country:US
Mailing Address - Phone:760-305-4777
Mailing Address - Fax:
Practice Address - Street 1:550 W VISTA WAY STE 202
Practice Address - Street 2:
Practice Address - City:VISTA
Practice Address - State:CA
Practice Address - Zip Code:92083-5736
Practice Address - Country:US
Practice Address - Phone:760-305-4777
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-07-05
Last Update Date:2021-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
171M00000X
CA9851101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA9851OtherCALIFORNIA ASSOCIATION OF DUI TREATMENT PROGRAMS