Provider Demographics
NPI:1407117500
Name:JIMENEZ, JOHANNY
Entity Type:Individual
Prefix:
First Name:JOHANNY
Middle Name:
Last Name:JIMENEZ
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 1:15 POST AVE
Mailing Address - Street 2:APT 3G
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10034-5844
Mailing Address - Country:US
Mailing Address - Phone:718-812-5425
Mailing Address - Fax:
Practice Address - Street 1:2336 ANDREWS AVE
Practice Address - Street 2:2ND FLOOR
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10468-6001
Practice Address - Country:US
Practice Address - Phone:718-561-5300
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-06-05
Last Update Date:2014-11-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY088856-1174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY14951OtherNYC SC ID