Provider Demographics
NPI:1720568611
Name:JIMENEZ, SHELBY RAE (PTA)
Entity Type:Individual
Prefix:
First Name:SHELBY
Middle Name:RAE
Last Name:JIMENEZ
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4130 N PRESTON AVE
Mailing Address - Street 2:
Mailing Address - City:WASILLA
Mailing Address - State:AK
Mailing Address - Zip Code:99654-1352
Mailing Address - Country:US
Mailing Address - Phone:907-414-4392
Mailing Address - Fax:
Practice Address - Street 1:3190 E MERIDIAN PARK LOOP STE 206A
Practice Address - Street 2:
Practice Address - City:WASILLA
Practice Address - State:AK
Practice Address - Zip Code:99654-7422
Practice Address - Country:US
Practice Address - Phone:907-373-9462
Practice Address - Fax:907-373-9463
Is Sole Proprietor?:Yes
Enumeration Date:2018-08-20
Last Update Date:2018-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK116806225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant