Provider Demographics
NPI:1952089708
Name:JIMENEZ PEREZ, PEDRO
Entity Type:Individual
Prefix:
First Name:PEDRO
Middle Name:
Last Name:JIMENEZ PEREZ
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 1:16170 SW 107TH PL
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33157-2970
Mailing Address - Country:US
Mailing Address - Phone:754-236-1497
Mailing Address - Fax:754-236-1497
Practice Address - Street 1:16170 SW 107TH PL
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33157-2970
Practice Address - Country:US
Practice Address - Phone:754-236-1497
Practice Address - Fax:754-236-1497
Is Sole Proprietor?:Yes
Enumeration Date:2023-07-10
Last Update Date:2023-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLBACB800822106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician