Provider Demographics
NPI:1730313388
Name:JIMENEZ, JOHN B
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:B
Last Name:JIMENEZ
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 1:446 LINNIE CANAL
Mailing Address - Street 2:
Mailing Address - City:VENICE
Mailing Address - State:CA
Mailing Address - Zip Code:90291-4622
Mailing Address - Country:US
Mailing Address - Phone:310-614-5049
Mailing Address - Fax:
Practice Address - Street 1:1701 ZONAL AVE
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90033-1065
Practice Address - Country:US
Practice Address - Phone:323-223-6146
Practice Address - Fax:323-223-6399
Is Sole Proprietor?:No
Enumeration Date:2009-05-12
Last Update Date:2009-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program