Provider Demographics
NPI:1588860399
Name:JIMENEZ, JUANA
Entity Type:Individual
Prefix:
First Name:JUANA
Middle Name:
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:PO BOX 304
Mailing Address - Street 2:SUITE A
Mailing Address - City:FAIRFIELD
Mailing Address - State:CA
Mailing Address - Zip Code:94533-0030
Mailing Address - Country:US
Mailing Address - Phone:707-422-0464
Mailing Address - Fax:707-422-0465
Practice Address - Street 1:490 CHADBOURNE RD
Practice Address - Street 2:SUITE A
Practice Address - City:FAIRFIELD
Practice Address - State:CA
Practice Address - Zip Code:94534-9613
Practice Address - Country:US
Practice Address - Phone:707-422-0464
Practice Address - Fax:707-422-0465
Is Sole Proprietor?:No
Enumeration Date:2007-06-27
Last Update Date:2010-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health