Provider Demographics
NPI:1043984735
Name:JIMENEZ, KRISTY LEE (CB1201986)
Entity Type:Individual
Prefix:
First Name:KRISTY
Middle Name:LEE
Last Name:JIMENEZ
Suffix:
Gender:F
Credentials:CB1201986
Other - Prefix:
Other - First Name:KRISTY
Other - Middle Name:LEE
Other - Last Name:JIMENEZ
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:KRISTY LEE JARAMILLO
Mailing Address - Street 1:5301 TIETON DR
Mailing Address - Street 2:
Mailing Address - City:YAKIMA
Mailing Address - State:WA
Mailing Address - Zip Code:98908-3479
Mailing Address - Country:US
Mailing Address - Phone:509-965-7100
Mailing Address - Fax:
Practice Address - Street 1:5301 TIETON DR
Practice Address - Street 2:
Practice Address - City:YAKIMA
Practice Address - State:WA
Practice Address - Zip Code:98908-3479
Practice Address - Country:US
Practice Address - Phone:509-965-7100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-08-05
Last Update Date:2021-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WACB61201986106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician