Provider Demographics
NPI:1528181070
Name:JIMINEZ, MARIO R
Entity Type:Individual
Prefix:
First Name:MARIO
Middle Name:R
Last Name:JIMINEZ
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 1:30 W SIMPSON ST
Mailing Address - Street 2:APT A
Mailing Address - City:EUREKA
Mailing Address - State:CA
Mailing Address - Zip Code:95501-5333
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:507 F ST
Practice Address - Street 2:
Practice Address - City:EUREKA
Practice Address - State:CA
Practice Address - Zip Code:95501-1009
Practice Address - Country:US
Practice Address - Phone:707-441-5510
Practice Address - Fax:707-441-5581
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-09
Last Update Date:2010-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
No101Y00000XBehavioral Health & Social Service ProvidersCounselor