Provider Demographics
NPI:1659931095
Name:ORTIZJIMENEZ, TERESA CONSEPCION
Entity Type:Individual
Prefix:
First Name:TERESA
Middle Name:CONSEPCION
Last Name:ORTIZJIMENEZ
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 1:8200 HAVEN AVE APT 14213
Mailing Address - Street 2:
Mailing Address - City:RANCHO CUCAMONGA
Mailing Address - State:CA
Mailing Address - Zip Code:91730-6990
Mailing Address - Country:US
Mailing Address - Phone:909-600-9519
Mailing Address - Fax:
Practice Address - Street 1:1425 W FOOTHILL BLVD
Practice Address - Street 2:
Practice Address - City:UPLAND
Practice Address - State:CA
Practice Address - Zip Code:91786-8007
Practice Address - Country:US
Practice Address - Phone:909-600-9519
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-06-18
Last Update Date:2019-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator