Healthcare Provider Details

I. General information

NPI: 1235759788
Provider Name (Legal Business Name): JUAN JIMENEZ JR. CPT
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/24/2020
Last Update Date: 04/24/2020
Certification Date: 04/24/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1860 E 120TH ST
LOS ANGELES CA
90059
US

IV. Provider business mailing address

1000 W 130TH ST
COMPTON CA
90222-1914
US

V. Phone/Fax

Practice location:
  • Phone: 424-239-8327
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code246RP1900X
TaxonomyPhlebotomy Technician
License NumberCPT01009982
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: