Provider Demographics
NPI:1740059153
Name:JIMENEZ, JENNIE
Entity type:Individual
Prefix:
First Name:JENNIE
Middle Name:
Last Name:JIMENEZ
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13973 SW 119TH AVE
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33186-6202
Mailing Address - Country:US
Mailing Address - Phone:305-767-9114
Mailing Address - Fax:
Practice Address - Street 1:13973 SW 119TH AVE
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33186-6202
Practice Address - Country:US
Practice Address - Phone:305-767-9114
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-12-27
Last Update Date:2024-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRBT-23-257076106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician