Provider Demographics
NPI:1679189724
Name:JIMMY, IFEANYI
Entity Type:Individual
Prefix:
First Name:IFEANYI
Middle Name:
Last Name:JIMMY
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 1:302 CHERRY LN
Mailing Address - Street 2:
Mailing Address - City:MANTECA
Mailing Address - State:CA
Mailing Address - Zip Code:95337-4311
Mailing Address - Country:US
Mailing Address - Phone:530-893-0758
Mailing Address - Fax:
Practice Address - Street 1:302 CHERRY LN
Practice Address - Street 2:
Practice Address - City:MANTECA
Practice Address - State:CA
Practice Address - Zip Code:95337-4311
Practice Address - Country:US
Practice Address - Phone:530-893-0758
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-09-23
Last Update Date:2023-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA132326106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist