Provider Demographics
NPI:1801918933
Name:JIMENEZ, MARCIAL RAYA SR
Entity type:Individual
Prefix:MR
First Name:MARCIAL
Middle Name:RAYA
Last Name:JIMENEZ
Suffix:SR
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 1:217 E LA MESA AVE
Mailing Address - Street 2:
Mailing Address - City:STOCKTON
Mailing Address - State:CA
Mailing Address - Zip Code:95207-3049
Mailing Address - Country:US
Mailing Address - Phone:209-468-3560
Mailing Address - Fax:209-468-3568
Practice Address - Street 1:56 S LINCOLN ST
Practice Address - Street 2:
Practice Address - City:STOCKTON
Practice Address - State:CA
Practice Address - Zip Code:95203-3100
Practice Address - Country:US
Practice Address - Phone:209-468-3560
Practice Address - Fax:209-468-3568
Is Sole Proprietor?:No
Enumeration Date:2007-04-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAJ0503011401101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)