Provider Demographics
NPI:1295318194
Name:JIMENEZ, OMAR JR
Entity type:Individual
Prefix:
First Name:OMAR
Middle Name:
Last Name:JIMENEZ
Suffix:JR
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 1:11908 BEXLEY DR
Mailing Address - Street 2:
Mailing Address - City:WHITTIER
Mailing Address - State:CA
Mailing Address - Zip Code:90606-2015
Mailing Address - Country:US
Mailing Address - Phone:562-556-0012
Mailing Address - Fax:
Practice Address - Street 1:6043 HOLLYWOOD BLVD
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90028-5411
Practice Address - Country:US
Practice Address - Phone:562-556-0012
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-04-29
Last Update Date:2021-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CARN95230454163WM0705X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WM0705XNursing Service ProvidersRegistered NurseMedical-Surgical