Provider Demographics
NPI:1306197819
Name:JIMENEZ, JESSICA MARIE (PA-C)
Entity Type:Individual
Prefix:MISS
First Name:JESSICA
Middle Name:MARIE
Last Name:JIMENEZ
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1550 SUPERIOR AVE
Mailing Address - Street 2:
Mailing Address - City:COSTA MESA
Mailing Address - State:CA
Mailing Address - Zip Code:92627-3653
Mailing Address - Country:US
Mailing Address - Phone:949-270-2100
Mailing Address - Fax:949-650-4458
Practice Address - Street 1:1550 SUPERIOR AVE
Practice Address - Street 2:
Practice Address - City:COSTA MESA
Practice Address - State:CA
Practice Address - Zip Code:92627-3653
Practice Address - Country:US
Practice Address - Phone:949-270-2100
Practice Address - Fax:949-650-4458
Is Sole Proprietor?:No
Enumeration Date:2012-09-24
Last Update Date:2019-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMPA2012-0041363A00000X
CAPA22326363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant