Healthcare Provider Details

I. General information

NPI: 1770705360
Provider Name (Legal Business Name): JORGE LUIS JIMENEZ M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/03/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

CLINICA LAS AMERICAS AVE. F. D. ROOSEVELT #400, SUITE 410
SAN JUAN PR
00918
US

IV. Provider business mailing address

CLINICA LAS AMERICAS AVE. F. D. ROOSEVELT #400, SUITE 410
SAN JUAN PR
00918
US

V. Phone/Fax

Practice location:
  • Phone: 787-753-6414
  • Fax: 787-763-7125
Mailing address:
  • Phone: 787-753-6414
  • Fax: 787-763-7125

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084D0003X
TaxonomyDiagnostic Neuroimaging (Psychiatry & Neurology) Physician
License Number4228
License Number StatePR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: