Provider Demographics
NPI:1003900697
Name:JIMENEZ, WAYNE P (PT)
Entity Type:Individual
Prefix:
First Name:WAYNE
Middle Name:P
Last Name:JIMENEZ
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:921 W BEACON ST
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:MS
Mailing Address - Zip Code:39350-3229
Mailing Address - Country:US
Mailing Address - Phone:601-650-0002
Mailing Address - Fax:601-650-9902
Practice Address - Street 1:464 CHURCH RD STE 400
Practice Address - Street 2:
Practice Address - City:MADISON
Practice Address - State:MS
Practice Address - Zip Code:39110-6940
Practice Address - Country:US
Practice Address - Phone:601-650-0002
Practice Address - Fax:601-899-0088
Is Sole Proprietor?:No
Enumeration Date:2006-10-03
Last Update Date:2019-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSPT0331225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist