Provider Demographics
NPI:1417958927
Name:ZIMMER, JACQUELINE LEE (PHD)
Entity Type:Individual
Prefix:DR
First Name:JACQUELINE
Middle Name:LEE
Last Name:ZIMMER
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:710 LONSDALE LN
Mailing Address - Street 2:
Mailing Address - City:VISTA
Mailing Address - State:CA
Mailing Address - Zip Code:92084-4422
Mailing Address - Country:US
Mailing Address - Phone:760-224-4811
Mailing Address - Fax:
Practice Address - Street 1:710 LONSDALE LN
Practice Address - Street 2:
Practice Address - City:VISTA
Practice Address - State:CA
Practice Address - Zip Code:92084-4422
Practice Address - Country:US
Practice Address - Phone:760-224-4811
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-09
Last Update Date:2015-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY8386103TC0700X, 103TH0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103TH0100XBehavioral Health & Social Service ProvidersPsychologistHealth Service
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPM0083860Medicaid
CP8386Medicare ID - Type Unspecified
R31393Medicare UPIN