Basic Information
| Provider Information | |||||||||
| NPI: | 1003900697 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | JIMENEZ | ||||||||
| FirstName: | WAYNE | ||||||||
| MiddleName: | P | ||||||||
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| Credential: | PT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 921 W BEACON ST | ||||||||
| Address2: | |||||||||
| City: | PHILADELPHIA | ||||||||
| State: | MS | ||||||||
| PostalCode: | 393503229 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6016500002 | ||||||||
| FaxNumber: | 6016509902 | ||||||||
| Practice Location | |||||||||
| Address1: | 464 CHURCH RD STE 400 | ||||||||
| Address2: | |||||||||
| City: | MADISON | ||||||||
| State: | MS | ||||||||
| PostalCode: | 391106940 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6016500002 | ||||||||
| FaxNumber: | 6018990088 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/03/2006 | ||||||||
| LastUpdateDate: | 05/15/2019 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | PT0331 | MS | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
No ID Information.