Provider Demographics
NPI:1568003226
Name:JIMENEZ, ELISA
Entity Type:Individual
Prefix:
First Name:ELISA
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 1:516 CHESTNUT ST
Mailing Address - Street 2:
Mailing Address - City:SANTA CRUZ
Mailing Address - State:CA
Mailing Address - Zip Code:95060-3669
Mailing Address - Country:US
Mailing Address - Phone:831-423-9015
Mailing Address - Fax:831-423-9098
Practice Address - Street 1:516 CHESTNUT ST
Practice Address - Street 2:
Practice Address - City:SANTA CRUZ
Practice Address - State:CA
Practice Address - Zip Code:95060-3669
Practice Address - Country:US
Practice Address - Phone:831-423-9015
Practice Address - Fax:831-423-9098
Is Sole Proprietor?:No
Enumeration Date:2019-10-03
Last Update Date:2023-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA172V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker