Healthcare Provider Details

I. General information

NPI: 1306867700
Provider Name (Legal Business Name): WANDA JIMENEZ M.D.M.P.H
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/21/2006
Last Update Date: 07/19/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1707 COOKS HILL RD
CENTRALIA WA
98531-9071
US

IV. Provider business mailing address

1707 COOKS HILL RD
CENTRALIA WA
98531-9071
US

V. Phone/Fax

Practice location:
  • Phone: 360-736-1961
  • Fax:
Mailing address:
  • Phone: 360-736-1965
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2083P0901X
TaxonomyPublic Health & General Preventive Medicine Physician
License Number175463
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberMD00048802
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: