Provider Demographics
NPI:1982215570
Name:JIMENEZ, KACI LYNN
Entity Type:Individual
Prefix:MRS
First Name:KACI
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 1:19362 W WOODLANDS AVE
Mailing Address - Street 2:
Mailing Address - City:BUCKEYE
Mailing Address - State:AZ
Mailing Address - Zip Code:85326-5831
Mailing Address - Country:US
Mailing Address - Phone:623-980-5232
Mailing Address - Fax:
Practice Address - Street 1:19362 W WOODLANDS AVE
Practice Address - Street 2:
Practice Address - City:BUCKEYE
Practice Address - State:AZ
Practice Address - Zip Code:85326-5831
Practice Address - Country:US
Practice Address - Phone:623-980-5232
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-08-16
Last Update Date:2020-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program