Provider Demographics
NPI:1538582424
Name:JIMENEZ, AGUSTIN RAUL (BCBA)
Entity type:Individual
Prefix:
First Name:AGUSTIN
Middle Name:RAUL
Last Name:JIMENEZ
Suffix:
Gender:M
Credentials:BCBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:370 W. SIERRA MADRE BLVD
Mailing Address - Street 2:B
Mailing Address - City:SIERRA MADRE
Mailing Address - State:CA
Mailing Address - Zip Code:91024
Mailing Address - Country:US
Mailing Address - Phone:626-355-5160
Mailing Address - Fax:626-355-5173
Practice Address - Street 1:370 W. SIERRA MADRE BLVD
Practice Address - Street 2:B
Practice Address - City:SIERRA MADRE
Practice Address - State:CA
Practice Address - Zip Code:91024
Practice Address - Country:US
Practice Address - Phone:626-355-5160
Practice Address - Fax:626-355-5173
Is Sole Proprietor?:No
Enumeration Date:2014-01-28
Last Update Date:2014-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA1-13-14900103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst