Healthcare Provider Details

I. General information

NPI: 1114826112
Provider Name (Legal Business Name): IVAN JIMENEZ PTA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/04/2026
Last Update Date: 11/04/2026
Certification Date: 11/04/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

511 W VISALIA RD
EXETER CA
93221-1019
US

IV. Provider business mailing address

511 W VISALIA RD
EXETER CA
93221-1019
US

V. Phone/Fax

Practice location:
  • Phone: 559-592-7117
  • Fax: 559-592-7112
Mailing address:
  • Phone: 559-592-7117
  • Fax: 559-592-7112

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number55094
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: