Provider Demographics
NPI:1770143885
Name:JIMENEZ, MYRIAM JANNETTE (PTA)
Entity type:Individual
Prefix:
First Name:MYRIAM
Middle Name:JANNETTE
Last Name:JIMENEZ
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 61160
Mailing Address - Street 2:
Mailing Address - City:CORPUS CHRISTI
Mailing Address - State:TX
Mailing Address - Zip Code:78466-1160
Mailing Address - Country:US
Mailing Address - Phone:361-884-2904
Mailing Address - Fax:361-857-0572
Practice Address - Street 1:1714 BOCA CHICA BLVD
Practice Address - Street 2:
Practice Address - City:BROWNSVILLE
Practice Address - State:TX
Practice Address - Zip Code:78520-8141
Practice Address - Country:US
Practice Address - Phone:956-544-2401
Practice Address - Fax:956-504-2234
Is Sole Proprietor?:No
Enumeration Date:2019-06-20
Last Update Date:2019-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX2012415225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant