Provider Demographics
NPI:1568167690
Name:JIMENEZ, IXELL MARISOL
Entity Type:Individual
Prefix:
First Name:IXELL
Middle Name:MARISOL
Last Name:JIMENEZ
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:957 CHARTER OAK AVE
Mailing Address - Street 2:
Mailing Address - City:SAINT HELENA
Mailing Address - State:CA
Mailing Address - Zip Code:94574-1313
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2310 1ST ST
Practice Address - Street 2:
Practice Address - City:NAPA
Practice Address - State:CA
Practice Address - Zip Code:94559-2239
Practice Address - Country:US
Practice Address - Phone:707-224-8226
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-03-30
Last Update Date:2023-11-27
Deactivation Date:2023-10-30
Deactivation Code:
Reactivation Date:2023-11-24
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker