Provider Demographics
NPI:1124741251
Name:JIMENEZ, MARTHA C (LCSW)
Entity type:Individual
Prefix:
First Name:MARTHA
Middle Name:C
Last Name:JIMENEZ
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:946 GLASS BEACH DR
Mailing Address - Street 2:
Mailing Address - City:FORT BRAGG
Mailing Address - State:CA
Mailing Address - Zip Code:95437-3063
Mailing Address - Country:US
Mailing Address - Phone:909-709-4182
Mailing Address - Fax:
Practice Address - Street 1:44261 LITTLE LAKE ROAD
Practice Address - Street 2:
Practice Address - City:MENDOCINO
Practice Address - State:CA
Practice Address - Zip Code:95460-9546
Practice Address - Country:US
Practice Address - Phone:707-397-7656
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-09-23
Last Update Date:2022-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA1100331041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical