Provider Demographics
NPI:1679141063
Name:JIMENEZ, MICHAEL ROBERT
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:ROBERT
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 1:6475 MEADOWBROOK CIR
Mailing Address - Street 2:
Mailing Address - City:WORTHINGTON
Mailing Address - State:OH
Mailing Address - Zip Code:43085-2864
Mailing Address - Country:US
Mailing Address - Phone:614-832-5961
Mailing Address - Fax:
Practice Address - Street 1:561 MELISSA DR
Practice Address - Street 2:
Practice Address - City:OXFORD
Practice Address - State:OH
Practice Address - Zip Code:45056-2537
Practice Address - Country:US
Practice Address - Phone:614-832-5961
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-06-14
Last Update Date:2021-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes385HR2065XRespite Care FacilityRespite CareRespite Care, Physical Disabilities, Child