Provider Demographics
NPI:1265002844
Name:JIMENEZ, TERA LUANE (LPN)
Entity type:Individual
Prefix:MRS
First Name:TERA
Middle Name:LUANE
Last Name:JIMENEZ
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:TERA
Other - Middle Name:LUANE
Other - Last Name:KENNEDY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LPN
Mailing Address - Street 1:2557 LINCOLN AVE
Mailing Address - Street 2:
Mailing Address - City:OGDEN
Mailing Address - State:UT
Mailing Address - Zip Code:84401-1307
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2557 LINCOLN AVE
Practice Address - Street 2:
Practice Address - City:OGDEN
Practice Address - State:UT
Practice Address - Zip Code:84401-1307
Practice Address - Country:US
Practice Address - Phone:801-622-5272
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-06-28
Last Update Date:2021-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT119097543101164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse