Provider Demographics
NPI:1457640682
Name:JIMMERSON, DANA
Entity Type:Individual
Prefix:
First Name:DANA
Middle Name:
Last Name:JIMMERSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4420 N VARSITY AVE APT 1095
Mailing Address - Street 2:
Mailing Address - City:SAN BERNARDINO
Mailing Address - State:CA
Mailing Address - Zip Code:92407-7012
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:15095 AMARGOSA RD STE 201
Practice Address - Street 2:
Practice Address - City:VICTORVILLE
Practice Address - State:CA
Practice Address - Zip Code:92394-1875
Practice Address - Country:US
Practice Address - Phone:760-245-4695
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-03-28
Last Update Date:2011-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health