Healthcare Provider Details

I. General information

NPI: 1669513586
Provider Name (Legal Business Name): ANTONIO JIMENEZ JR.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/12/2007
Last Update Date: 05/15/2026
Certification Date: 05/15/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1007 N LAKE AVE 1007 N. LAKE AVE
PASADENA CA
91104-4521
US

IV. Provider business mailing address

2626 JEFFRIES AVE
LOS ANGELES CA
90065-1550
US

V. Phone/Fax

Practice location:
  • Phone: 626-808-9746
  • Fax:
Mailing address:
  • Phone: 909-525-3224
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number137128
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code167G00000X
TaxonomyLicensed Psychiatric Technician
License Number33379
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: