Provider Demographics
NPI:1649307844
Name:JIMENEZ, TIMOTHY EUGENE
Entity type:Individual
Prefix:
First Name:TIMOTHY
Middle Name:EUGENE
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 1:33212 KUHIO HIGHWAY
Mailing Address - Street 2:KAUAI COMMUNITY MENTAL HEALTH CENTER
Mailing Address - City:LIHUE
Mailing Address - State:HI
Mailing Address - Zip Code:96766-1142
Mailing Address - Country:US
Mailing Address - Phone:808-274-3190
Mailing Address - Fax:808-274-3194
Practice Address - Street 1:41751 KUHIO HIGHWAY
Practice Address - Street 2:FRIENDSHIP HOUSE PSYCHO SOCIAL REHABILITATION PROGRAM
Practice Address - City:KAPAA
Practice Address - State:HI
Practice Address - Zip Code:96746-2064
Practice Address - Country:US
Practice Address - Phone:808-821-4480
Practice Address - Fax:808-821-4483
Is Sole Proprietor?:No
Enumeration Date:2007-02-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
HI53937202Medicaid