MEDICARE: CHRISTOPHER JIMENEZ

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	103K00000X	Behavior Analyst

General Provider Information

NPI Number	:	1962193367
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	CHRISTOPHER JIMENEZ

Provider Business Mailing Address
First Line	:	1415 E DATE ST APT 104
Second Line	:
City	:	SAN BERNARDINO
State	:	CA
Zip	:	92404-4261
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	1415 E DATE ST APT 104
Second Line	:
City	:	SAN BERNARDINO
State	:	CA
Zip	:	92404-4261
Country	:	US
Telephone Number	:	951-569-7486
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/17/2023
Last Update Date	:	05/17/2023

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