Provider Demographics
NPI:1992805048
Name:JIMENEZ, EDNA (PSYD)
Entity type:Individual
Prefix:
First Name:EDNA
Middle Name:
Last Name:JIMENEZ
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:100 E THOUSAND OAKS BLVD STE 217
Mailing Address - Street 2:
Mailing Address - City:THOUSAND OAKS
Mailing Address - State:CA
Mailing Address - Zip Code:91360-8177
Mailing Address - Country:US
Mailing Address - Phone:818-371-8818
Mailing Address - Fax:805-778-1061
Practice Address - Street 1:100 E THOUSAND OAKS BLVD STE 217
Practice Address - Street 2:
Practice Address - City:THOUSAND OAKS
Practice Address - State:CA
Practice Address - Zip Code:91360-8177
Practice Address - Country:US
Practice Address - Phone:818-371-8818
Practice Address - Fax:805-778-1061
Is Sole Proprietor?:No
Enumeration Date:2006-09-25
Last Update Date:2020-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY14574103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical