Healthcare Provider Details

I. General information

NPI: 1245882190
Provider Name (Legal Business Name): JOSE ALFREDO JIMENEZ AA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/11/2019
Last Update Date: 02/22/2024
Certification Date: 02/22/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5000 W SUNSET BLVD
LOS ANGELES CA
90027-5861
US

IV. Provider business mailing address

2008 N GAREY AVE
POMONA CA
91767-2722
US

V. Phone/Fax

Practice location:
  • Phone: 323-439-8315
  • Fax: 909-865-9281
Mailing address:
  • Phone: 909-623-6131
  • Fax: 909-865-9281

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code172V00000X
TaxonomyCommunity Health Worker
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: