Provider Demographics
NPI:1609945328
Name:JIMENEZ, JOHN ANSEL CRUZ (PT)
Entity Type:Individual
Prefix:
First Name:JOHN ANSEL
Middle Name:CRUZ
Last Name:JIMENEZ
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:100 E MANANA BLVD STE 1
Mailing Address - Street 2:
Mailing Address - City:CLOVIS
Mailing Address - State:NM
Mailing Address - Zip Code:88101-3503
Mailing Address - Country:US
Mailing Address - Phone:575-366-5014
Mailing Address - Fax:575-366-5015
Practice Address - Street 1:100 E MANANA BLVD
Practice Address - Street 2:UNIT 1
Practice Address - City:CLOVIS
Practice Address - State:NM
Practice Address - Zip Code:88101-3503
Practice Address - Country:US
Practice Address - Phone:575-366-5014
Practice Address - Fax:575-366-5015
Is Sole Proprietor?:No
Enumeration Date:2006-11-07
Last Update Date:2018-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM3209225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM29880360Medicaid