MEDICARE: DR. JOVENCIO JIMENEZ III DPT

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	225100000X	Physical Therapist	PT25149	CA

General Provider Information

NPI Number	:	1407874720
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. JOVENCIO JIMENEZ III DPT

Provider Business Mailing Address
First Line	:	2129 N BUENA VISTA ST
Second Line	:
City	:	BURBANK
State	:	CA
Zip	:	91504-3307
Country	:	US
Telephone Number	:	818-955-8507
Fax Number	:

Provider Business Practice Location Address
First Line	:	1415 E COLORADO ST
Second Line	:
City	:	GLENDALE
State	:	CA
Zip	:	91205-1533
Country	:	US
Telephone Number	:	818-240-5512
Fax Number	:

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

Provider Enumeration Date	:	07/17/2006
Last Update Date	:	07/08/2007

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