Healthcare Provider Details

I. General information

NPI: 1396399515
Provider Name (Legal Business Name): PERCY J. JIMENEZ
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/25/2019
Last Update Date: 07/25/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

23 BEEKMAN ST
STATEN ISLAND NY
10302-2006
US

IV. Provider business mailing address

23 BEEKMAN ST
STATEN ISLAND NY
10302-2006
US

V. Phone/Fax

Practice location:
  • Phone: 347-319-3009
  • Fax:
Mailing address:
  • Phone: 347-319-3009
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP1600X
TaxonomyPastoral Counselor
License NumberTTC-III-07-03-6989
License Number StatePR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: