Provider Demographics
NPI:1306867700
Name:JIMENEZ, WANDA (MDMPH)
Entity Type:Individual
Prefix:DR
First Name:WANDA
Middle Name:
Last Name:JIMENEZ
Suffix:
Gender:F
Credentials:MDMPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1707 COOKS HILL RD
Mailing Address - Street 2:
Mailing Address - City:CENTRALIA
Mailing Address - State:WA
Mailing Address - Zip Code:98531-9071
Mailing Address - Country:US
Mailing Address - Phone:360-736-1965
Mailing Address - Fax:
Practice Address - Street 1:1707 COOKS HILL RD
Practice Address - Street 2:
Practice Address - City:CENTRALIA
Practice Address - State:WA
Practice Address - Zip Code:98531-9071
Practice Address - Country:US
Practice Address - Phone:360-736-1961
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-21
Last Update Date:2010-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY1754632083P0901X
WAMD00048802207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2083P0901XAllopathic & Osteopathic PhysiciansPreventive MedicinePublic Health & General Preventive Medicine
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA0239255OtherLABOR & INDUSTRIES
8118JIOtherREGENCE
WA8530024Medicaid
NYWJ072F3610Medicare ID - Type Unspecified
8118JIOtherREGENCE
WA0568510001Medicare NSC
G8875842Medicare PIN
WA8530024Medicaid