Basic Information
| Provider Information | |||||||||
| NPI: | 1255370979 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | JIMENEZ | ||||||||
| FirstName: | YVONNE | ||||||||
| MiddleName: | MARIE | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 35318 EAGLE WAY STE 40 | ||||||||
| Address2: | |||||||||
| City: | CHICAGO | ||||||||
| State: | IL | ||||||||
| PostalCode: | 606781353 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3175284868 | ||||||||
| FaxNumber: | 3178658319 | ||||||||
| Practice Location | |||||||||
| Address1: | 3700 W 203RD ST | ||||||||
| Address2: | SUITE 301 | ||||||||
| City: | OLYMPIA FIELDS | ||||||||
| State: | IL | ||||||||
| PostalCode: | 604611180 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7086792850 | ||||||||
| FaxNumber: | 7085033810 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/06/2006 | ||||||||
| LastUpdateDate: | 12/15/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 12/15/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 036110075 | IL | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 036110075 | 05 | IL | MEDICAID |