Provider Demographics
NPI:1629121264
Name:JIE, JIMMY (ABOC)
Entity Type:Individual
Prefix:MR
First Name:JIMMY
Middle Name:
Last Name:JIE
Suffix:
Gender:M
Credentials:ABOC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:18557 SHERMAN WAY
Mailing Address - Street 2:
Mailing Address - City:RESEDA
Mailing Address - State:CA
Mailing Address - Zip Code:91335-4144
Mailing Address - Country:US
Mailing Address - Phone:818-344-3064
Mailing Address - Fax:818-344-3065
Practice Address - Street 1:18557 SHERMAN WAY
Practice Address - Street 2:
Practice Address - City:RESEDA
Practice Address - State:CA
Practice Address - Zip Code:91335-4144
Practice Address - Country:US
Practice Address - Phone:818-344-3064
Practice Address - Fax:818-344-3065
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-18
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CASL2290156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician
Provider Identifiers
StateIdentifier IDID TypeIssuer
CADX0066770Medicaid