Provider Demographics
NPI:1669513586
Name:JIMENEZ, ANTONIO JR
Entity type:Individual
Prefix:
First Name:ANTONIO
Middle Name:
Last Name:JIMENEZ
Suffix:JR
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2626 JEFFRIES AVE
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90065-1550
Mailing Address - Country:US
Mailing Address - Phone:909-525-3224
Mailing Address - Fax:
Practice Address - Street 1:1007 N LAKE AVE
Practice Address - Street 2:1007 N. LAKE AVE
Practice Address - City:PASADENA
Practice Address - State:CA
Practice Address - Zip Code:91104-4521
Practice Address - Country:US
Practice Address - Phone:626-808-9746
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-12
Last Update Date:2025-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA33379167G00000X
171M00000X, 373H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes373H00000XNursing Service Related ProvidersDay Training/Habilitation Specialist
No167G00000XNursing Service ProvidersLicensed Psychiatric Technician
No171M00000XOther Service ProvidersCase Manager/Care Coordinator