Provider Demographics
NPI:1770254427
Name:JIMENEZ, KYLA MARIE
Entity Type:Individual
Prefix:MRS
First Name:KYLA
Middle Name:MARIE
Last Name:JIMENEZ
Suffix:
Gender:F
Credentials:
Other - Prefix:MS
Other - First Name:KYLA
Other - Middle Name:MARIE
Other - Last Name:STAATS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:6152 SPRUCE AVE
Mailing Address - Street 2:
Mailing Address - City:CLEARLAKE
Mailing Address - State:CA
Mailing Address - Zip Code:95422-9018
Mailing Address - Country:US
Mailing Address - Phone:707-350-1006
Mailing Address - Fax:
Practice Address - Street 1:39201 STATE ST
Practice Address - Street 2:
Practice Address - City:FREMONT
Practice Address - State:CA
Practice Address - Zip Code:94538-1437
Practice Address - Country:US
Practice Address - Phone:866-206-2008
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-09-22
Last Update Date:2021-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA106S00000X106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician