Provider Demographics
NPI:1609478007
Name:ZIMMERMANN, JIM
Entity Type:Individual
Prefix:
First Name:JIM
Middle Name:
Last Name:ZIMMERMANN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:520 PATTERSON BLVD APT 120
Mailing Address - Street 2:
Mailing Address - City:FAIRFIELD
Mailing Address - State:OH
Mailing Address - Zip Code:45014-2658
Mailing Address - Country:US
Mailing Address - Phone:817-301-8135
Mailing Address - Fax:
Practice Address - Street 1:520 PATTERSON BLVD APT 120
Practice Address - Street 2:
Practice Address - City:FAIRFIELD
Practice Address - State:OH
Practice Address - Zip Code:45014-2658
Practice Address - Country:US
Practice Address - Phone:817-301-8135
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-11-10
Last Update Date:2020-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHPA-0010155374U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide
Provider Identifiers
StateIdentifier IDID TypeIssuer
OHPA-0010155Medicaid