Provider Demographics
NPI:1669946091
Name:JIMENEZ, BRYAN
Entity type:Individual
Prefix:
First Name:BRYAN
Middle Name:
Last Name:JIMENEZ
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 1:21600 OXNARD ST STE 1800
Mailing Address - Street 2:
Mailing Address - City:WOODLAND HILLS
Mailing Address - State:CA
Mailing Address - Zip Code:91367-7807
Mailing Address - Country:US
Mailing Address - Phone:818-345-2345
Mailing Address - Fax:
Practice Address - Street 1:5750 DIVISION ST STE 104
Practice Address - Street 2:
Practice Address - City:RIVERSIDE
Practice Address - State:CA
Practice Address - Zip Code:92506-3259
Practice Address - Country:US
Practice Address - Phone:147-181-8668
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-01-18
Last Update Date:2019-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA106S00000X
101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician