Provider Demographics
NPI:1407874720
Name:JIMENEZ, JOVENCIO III (DPT)
Entity Type:Individual
Prefix:DR
First Name:JOVENCIO
Middle Name:
Last Name:JIMENEZ
Suffix:III
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2129 N BUENA VISTA ST
Mailing Address - Street 2:
Mailing Address - City:BURBANK
Mailing Address - State:CA
Mailing Address - Zip Code:91504-3307
Mailing Address - Country:US
Mailing Address - Phone:818-955-8507
Mailing Address - Fax:
Practice Address - Street 1:1415 E COLORADO ST
Practice Address - Street 2:
Practice Address - City:GLENDALE
Practice Address - State:CA
Practice Address - Zip Code:91205-1533
Practice Address - Country:US
Practice Address - Phone:818-240-5512
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT25149225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAW25149Medicare ID - Type Unspecified