Provider Demographics
NPI:1982142410
Name:JIMENEZ, EDGAR LEONEL
Entity Type:Individual
Prefix:
First Name:EDGAR
Middle Name:LEONEL
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:PO BOX 1764
Mailing Address - Street 2:
Mailing Address - City:CAMARILLO
Mailing Address - State:CA
Mailing Address - Zip Code:93011-1764
Mailing Address - Country:US
Mailing Address - Phone:805-284-5403
Mailing Address - Fax:
Practice Address - Street 1:555 RESERVOIR DR .
Practice Address - Street 2:SUITE 204-A
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92120
Practice Address - Country:US
Practice Address - Phone:619-822-1800
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-02-03
Last Update Date:2022-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No171M00000XOther Service ProvidersCase Manager/Care Coordinator
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health