Provider Demographics
NPI:1760546030
Name:JIMENEZ, JERRI LYNN
Entity Type:Individual
Prefix:MRS
First Name:JERRI
Middle Name:LYNN
Last Name:JIMENEZ
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 1:1042 W VINEYARD PLAINS DR
Mailing Address - Street 2:
Mailing Address - City:SAN TAN VALLEY
Mailing Address - State:AZ
Mailing Address - Zip Code:85143-3467
Mailing Address - Country:US
Mailing Address - Phone:480-272-8563
Mailing Address - Fax:
Practice Address - Street 1:1042 W VINEYARD PLAINS DR
Practice Address - Street 2:
Practice Address - City:SAN TAN VALLEY
Practice Address - State:AZ
Practice Address - Zip Code:85143-3467
Practice Address - Country:US
Practice Address - Phone:480-272-8563
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-21
Last Update Date:2010-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ9091385HR2055X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes385HR2055XRespite Care FacilityRespite CareRespite Care, Mental Illness, Child