Provider Demographics
NPI:1003693532
Name:JIMENEZ, THEODORE
Entity Type:Individual
Prefix:
First Name:THEODORE
Middle Name:
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 1:11620 CLAIM STAKE DR
Mailing Address - Street 2:
Mailing Address - City:RENO
Mailing Address - State:NV
Mailing Address - Zip Code:89506-7529
Mailing Address - Country:US
Mailing Address - Phone:775-340-6326
Mailing Address - Fax:775-525-2426
Practice Address - Street 1:1810 THRELKEL ST
Practice Address - Street 2:
Practice Address - City:RENO
Practice Address - State:NV
Practice Address - Zip Code:89512-3713
Practice Address - Country:US
Practice Address - Phone:775-325-8297
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-09-08
Last Update Date:2023-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator