MEDICARE: MR. JUAN M JIMENEZ

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	106E00000X	Assistant Behavior Analyst
2	106E00000X	Assistant Behavior Analyst		WA

General Provider Information

NPI Number	:	1376199760
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. JUAN M JIMENEZ

Provider Business Mailing Address
First Line	:	529 WEST 6TH ST
Second Line	:
City	:	PORT ANGELES
State	:	WA
Zip	:	98362-5805
Country	:	US
Telephone Number	:	360-643-9400
Fax Number	:

Provider Business Practice Location Address
First Line	:	529 W 6TH ST
Second Line	:
City	:	PORT ANGELES
State	:	WA
Zip	:	98362-5805
Country	:	US
Telephone Number	:	940-627-6918
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/13/2019
Last Update Date	:	09/04/2019

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