Provider Demographics
NPI:1497122980
Name:JIMENEZ, JERONIMO (MSOTR/L)
Entity Type:Individual
Prefix:
First Name:JERONIMO
Middle Name:
Last Name:JIMENEZ
Suffix:
Gender:M
Credentials:MSOTR/L
Other - Prefix:
Other - First Name:JERONIMO
Other - Middle Name:
Other - Last Name:JIMENEZ GONZALEZ
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:6086 CEDAR WOOD DR
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:MD
Mailing Address - Zip Code:21044-3675
Mailing Address - Country:US
Mailing Address - Phone:443-766-0298
Mailing Address - Fax:
Practice Address - Street 1:6086 CEDAR WOOD DR
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:MD
Practice Address - Zip Code:21044-3675
Practice Address - Country:US
Practice Address - Phone:443-766-0298
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-08-31
Last Update Date:2015-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD07336225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD07236OtherTHE MARYLAND STATE BOARD OF OCCUPATIONAL THERAPY PRACTICE