Provider Demographics
NPI:1235266883
Name:POWELL, JIMMIE ALLEN (MFT24610)
Entity Type:Individual
Prefix:
First Name:JIMMIE
Middle Name:ALLEN
Last Name:POWELL
Suffix:
Gender:M
Credentials:MFT24610
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:72629 SKYWARD WAY
Mailing Address - Street 2:
Mailing Address - City:PALM DESERT
Mailing Address - State:CA
Mailing Address - Zip Code:92260-6023
Mailing Address - Country:US
Mailing Address - Phone:760-674-1529
Mailing Address - Fax:760-347-0754
Practice Address - Street 1:83912 AVENUE 45 STE 9
Practice Address - Street 2:
Practice Address - City:INDIO
Practice Address - State:CA
Practice Address - Zip Code:92201-3338
Practice Address - Country:US
Practice Address - Phone:760-347-0754
Practice Address - Fax:760-347-8507
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMFT24610106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist