Provider Demographics
NPI:1639688831
Name:JIMENEZ, KALILA
Entity type:Individual
Prefix:MRS
First Name:KALILA
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 1:1828 253RD ST
Mailing Address - Street 2:
Mailing Address - City:LOMITA
Mailing Address - State:CA
Mailing Address - Zip Code:90717-1959
Mailing Address - Country:US
Mailing Address - Phone:702-203-4468
Mailing Address - Fax:
Practice Address - Street 1:16465 SIERRA LAKES PKWY STE 140
Practice Address - Street 2:
Practice Address - City:FONTANA
Practice Address - State:CA
Practice Address - Zip Code:92336-1242
Practice Address - Country:US
Practice Address - Phone:909-244-9593
Practice Address - Fax:833-903-0337
Is Sole Proprietor?:No
Enumeration Date:2017-09-20
Last Update Date:2024-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA123512106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist