Provider Demographics
NPI:1871001578
Name:JIMENEZ, JOSE
Entity Type:Individual
Prefix:
First Name:JOSE
Middle Name:
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 1:3697 BLAIR ST
Mailing Address - Street 2:
Mailing Address - City:CORONA
Mailing Address - State:CA
Mailing Address - Zip Code:92879-2002
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:108 W VICTORIA ST
Practice Address - Street 2:
Practice Address - City:GARDENA
Practice Address - State:CA
Practice Address - Zip Code:90248-3523
Practice Address - Country:US
Practice Address - Phone:310-715-2020
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-01-16
Last Update Date:2019-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225400000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRehabilitation Practitioner