Provider Demographics
NPI:1144461716
Name:JIMENEZ, ADAM-JOHN A
Entity type:Individual
Prefix:
First Name:ADAM-JOHN
Middle Name:A
Last Name:JIMENEZ
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1365 BLUEBIRD AVE
Mailing Address - Street 2:
Mailing Address - City:VENTURA
Mailing Address - State:CA
Mailing Address - Zip Code:93003-6154
Mailing Address - Country:US
Mailing Address - Phone:805-765-9050
Mailing Address - Fax:805-653-0567
Practice Address - Street 1:300 HILLMONT AVE
Practice Address - Street 2:
Practice Address - City:VENTURA
Practice Address - State:CA
Practice Address - Zip Code:93003-1651
Practice Address - Country:US
Practice Address - Phone:805-765-9050
Practice Address - Fax:805-653-0567
Is Sole Proprietor?:Yes
Enumeration Date:2009-03-11
Last Update Date:2009-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT28615167G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes167G00000XNursing Service ProvidersLicensed Psychiatric Technician