Provider Demographics
NPI:1699323725
Name:JIMENEZ ZAMORA, JAQUELINE
Entity type:Individual
Prefix:
First Name:JAQUELINE
Middle Name:
Last Name:JIMENEZ ZAMORA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:19012 SW 113TH PL
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33157
Mailing Address - Country:US
Mailing Address - Phone:786-624-7411
Mailing Address - Fax:
Practice Address - Street 1:19012 SW 113TH PL
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33157-7562
Practice Address - Country:US
Practice Address - Phone:786-624-7411
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-09-02
Last Update Date:2019-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRBT-15-03157106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior TechnicianGroup - Single Specialty