Provider Demographics
NPI:1730549478
Name:JIMENEZ, JOSE ALFREDO JR (MED)
Entity type:Individual
Prefix:
First Name:JOSE
Middle Name:ALFREDO
Last Name:JIMENEZ
Suffix:JR
Gender:M
Credentials:MED
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:800 LAKESIDE CIR APT 1333
Mailing Address - Street 2:
Mailing Address - City:LEWISVILLE
Mailing Address - State:TX
Mailing Address - Zip Code:75057-5105
Mailing Address - Country:US
Mailing Address - Phone:214-708-6268
Mailing Address - Fax:
Practice Address - Street 1:105 KATHRYN DR
Practice Address - Street 2:BLDG 3, STE D
Practice Address - City:LEWISVILLE
Practice Address - State:TX
Practice Address - Zip Code:75067-4216
Practice Address - Country:US
Practice Address - Phone:800-972-0643
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-02-23
Last Update Date:2016-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX13362101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)