Provider Demographics
NPI:1063810265
Name:JIMENEZ, JENNIFER DIANE (MA, CCC-SLP)
Entity type:Individual
Prefix:MRS
First Name:JENNIFER
Middle Name:DIANE
Last Name:JIMENEZ
Suffix:
Gender:F
Credentials:MA, CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:118 S SUNFLOWER AVE
Mailing Address - Street 2:
Mailing Address - City:OBERLIN
Mailing Address - State:KS
Mailing Address - Zip Code:67749-4956
Mailing Address - Country:US
Mailing Address - Phone:785-470-7677
Mailing Address - Fax:
Practice Address - Street 1:118 S SUNFLOWER AVE
Practice Address - Street 2:
Practice Address - City:OBERLIN
Practice Address - State:KS
Practice Address - Zip Code:67749-4956
Practice Address - Country:US
Practice Address - Phone:785-470-7677
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-12-21
Last Update Date:2014-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS2333235Z00000X
NE1485235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist