Provider Demographics
NPI:1649958869
Name:JIMENEZ, SIDNEY LESLIE (MA 93477)
Entity type:Individual
Prefix:MS
First Name:SIDNEY
Middle Name:LESLIE
Last Name:JIMENEZ
Suffix:
Gender:F
Credentials:MA 93477
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1603 S HIAWASSEE RD STE 105
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32835-6437
Mailing Address - Country:US
Mailing Address - Phone:407-508-0768
Mailing Address - Fax:
Practice Address - Street 1:1603 S HIAWASSEE RD STE 105
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32835-6437
Practice Address - Country:US
Practice Address - Phone:407-508-0768
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-07-07
Last Update Date:2024-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMA93477225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist