Provider Demographics
NPI:1093410136
Name:IDIMA, JENNIFER
Entity Type:Individual
Prefix:MRS
First Name:JENNIFER
Middle Name:
Last Name:IDIMA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2800 S MACGREGOR WAY
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77021-1032
Mailing Address - Country:US
Mailing Address - Phone:914-308-1217
Mailing Address - Fax:
Practice Address - Street 1:2800 S MACGREGOR WAY
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77021-1032
Practice Address - Country:US
Practice Address - Phone:914-308-1217
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-03-30
Last Update Date:2023-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1110552363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health