Provider Demographics
NPI:1033970017
Name:JIMENEZ, MADISON RAYNE
Entity Type:Individual
Prefix:
First Name:MADISON
Middle Name:RAYNE
Last Name:JIMENEZ
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:MADISON
Other - Middle Name:RAYNE
Other - Last Name:JIMENEZ
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2546 S 11TH ST APT E
Mailing Address - Street 2:
Mailing Address - City:JOINT BASE LEWIS MCCHORD
Mailing Address - State:WA
Mailing Address - Zip Code:98433-1804
Mailing Address - Country:US
Mailing Address - Phone:714-519-1799
Mailing Address - Fax:
Practice Address - Street 1:2546 S 11TH ST APT E
Practice Address - Street 2:
Practice Address - City:JOINT BASE LEWIS MCCHORD
Practice Address - State:WA
Practice Address - Zip Code:98433-1804
Practice Address - Country:US
Practice Address - Phone:714-519-1799
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-01-17
Last Update Date:2024-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician