Healthcare Provider Details

I. General information

NPI: 1629897475
Provider Name (Legal Business Name): AMANDA RENEE JIMENEZ PT, DPT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/08/2024
Last Update Date: 08/03/2026
Certification Date: 08/03/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

205 JEFFERSON ST
JEFFERSON CITY MO
65101-2901
US

IV. Provider business mailing address

4814 W 63RD ST
PRAIRIE VILLAGE KS
66208-1302
US

V. Phone/Fax

Practice location:
  • Phone: 573-522-8762
  • Fax:
Mailing address:
  • Phone: 832-602-1389
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number2025034618
License Number StateMO
# 2
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberCP034868T
License Number StateAR
# 3
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number1397253
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: