Provider Demographics
NPI:1053034801
Name:JIMENEZ, MARIA CARRILLO
Entity type:Individual
Prefix:
First Name:MARIA
Middle Name:CARRILLO
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 1:12598 CENTRAL AVE STE 122
Mailing Address - Street 2:
Mailing Address - City:CHINO
Mailing Address - State:CA
Mailing Address - Zip Code:91710-3500
Mailing Address - Country:US
Mailing Address - Phone:909-766-0096
Mailing Address - Fax:909-542-3161
Practice Address - Street 1:12598 CENTRAL AVE STE 122
Practice Address - Street 2:
Practice Address - City:CHINO
Practice Address - State:CA
Practice Address - Zip Code:91710-3500
Practice Address - Country:US
Practice Address - Phone:909-766-0096
Practice Address - Fax:909-542-3161
Is Sole Proprietor?:No
Enumeration Date:2022-09-26
Last Update Date:2022-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA12370101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health