Provider Demographics
NPI:1043014343
Name:JIMENEZ, MELISSA
Entity type:Individual
Prefix:
First Name:MELISSA
Middle Name:
Last Name:JIMENEZ
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:311 E REED ST APT 3
Mailing Address - Street 2:
Mailing Address - City:SAN JOSE
Mailing Address - State:CA
Mailing Address - Zip Code:95112-3884
Mailing Address - Country:US
Mailing Address - Phone:310-490-5793
Mailing Address - Fax:
Practice Address - Street 1:1700 WINCHESTER BLVD STE 101
Practice Address - Street 2:
Practice Address - City:CAMPBELL
Practice Address - State:CA
Practice Address - Zip Code:95008-1163
Practice Address - Country:US
Practice Address - Phone:408-824-9355
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-04-03
Last Update Date:2025-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CATBD106S00000X
106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician