Provider Demographics
NPI:1083185011
Name:JIMENEZ, JOSHUA
Entity Type:Individual
Prefix:
First Name:JOSHUA
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 1:257 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:MILLBURN
Mailing Address - State:NJ
Mailing Address - Zip Code:07041-1167
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:257 MAIN ST
Practice Address - Street 2:
Practice Address - City:MILLBURN
Practice Address - State:NJ
Practice Address - Zip Code:07041-1167
Practice Address - Country:US
Practice Address - Phone:862-900-0013
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-12-17
Last Update Date:2020-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0040742255A2300X
NJ25MT002774002255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer