Provider Demographics
NPI:1306546288
Name:JIMLA, JOHNNY
Entity type:Individual
Prefix:
First Name:JOHNNY
Middle Name:
Last Name:JIMLA
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 1:6428 LANDING WAY
Mailing Address - Street 2:
Mailing Address - City:HYATTSVILLE
Mailing Address - State:MD
Mailing Address - Zip Code:20784-4619
Mailing Address - Country:US
Mailing Address - Phone:667-383-5051
Mailing Address - Fax:
Practice Address - Street 1:2041 MLK JR AVENUE
Practice Address - Street 2:
Practice Address - City:SE WASHINGTON
Practice Address - State:DC
Practice Address - Zip Code:20020
Practice Address - Country:US
Practice Address - Phone:202-547-8450
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-03-08
Last Update Date:2023-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker