Provider Demographics
NPI:1942192505
Name:JIMINEZ, CARRIE NICHOLE
Entity type:Individual
Prefix:
First Name:CARRIE
Middle Name:NICHOLE
Last Name:JIMINEZ
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:328 33RD ST
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92102-4206
Mailing Address - Country:US
Mailing Address - Phone:619-274-4559
Mailing Address - Fax:
Practice Address - Street 1:1315 25TH ST
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92102-2107
Practice Address - Country:US
Practice Address - Phone:619-233-0067
Practice Address - Fax:619-233-3990
Is Sole Proprietor?:Yes
Enumeration Date:2025-07-17
Last Update Date:2025-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA19018101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)