Provider Demographics
NPI:1215662465
Name:JIMENEZ, ANTONIO (BA, RBT)
Entity type:Individual
Prefix:
First Name:ANTONIO
Middle Name:
Last Name:JIMENEZ
Suffix:
Gender:M
Credentials:BA, RBT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6330 MCLEOD DR STE 4
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89120-4431
Mailing Address - Country:US
Mailing Address - Phone:310-406-1500
Mailing Address - Fax:
Practice Address - Street 1:6330 MCLEOD DR STE 4
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89120-4431
Practice Address - Country:US
Practice Address - Phone:310-406-1500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-07-21
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NVRBT2763106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician