Provider Demographics
NPI:1164038279
Name:JIMENEZ, SUSANA (LMT)
Entity Type:Individual
Prefix:
First Name:SUSANA
Middle Name:
Last Name:JIMENEZ
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 2884
Mailing Address - Street 2:
Mailing Address - City:PORT ANGELES
Mailing Address - State:WA
Mailing Address - Zip Code:98362-0334
Mailing Address - Country:US
Mailing Address - Phone:360-809-3325
Mailing Address - Fax:
Practice Address - Street 1:104 N LAUREL ST STE 101
Practice Address - Street 2:
Practice Address - City:PORT ANGELES
Practice Address - State:WA
Practice Address - Zip Code:98362-2637
Practice Address - Country:US
Practice Address - Phone:360-809-3325
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-09-23
Last Update Date:2020-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA60925741225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist