Provider Demographics
NPI:1912556564
Name:JIMENEZ, FREDERIC (ATC, CSCS, USAW)
Entity Type:Individual
Prefix:
First Name:FREDERIC
Middle Name:
Last Name:JIMENEZ
Suffix:
Gender:M
Credentials:ATC, CSCS, USAW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:70B FREMONT ST APT 15B
Mailing Address - Street 2:
Mailing Address - City:BLOOMFIELD
Mailing Address - State:NJ
Mailing Address - Zip Code:07003-3464
Mailing Address - Country:US
Mailing Address - Phone:201-303-1214
Mailing Address - Fax:
Practice Address - Street 1:467 FRANKLIN ST
Practice Address - Street 2:
Practice Address - City:BLOOMFIELD
Practice Address - State:NJ
Practice Address - Zip Code:07003-3494
Practice Address - Country:US
Practice Address - Phone:973-748-9000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-09-06
Last Update Date:2019-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MT001597002255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic TrainerGroup - Single Specialty