Basic Information
| Provider Information | |||||||||
| NPI: | 1720568611 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | JIMENEZ | ||||||||
| FirstName: | SHELBY | ||||||||
| MiddleName: | RAE | ||||||||
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| Credential: | PTA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4130 N PRESTON AVE | ||||||||
| Address2: | |||||||||
| City: | WASILLA | ||||||||
| State: | AK | ||||||||
| PostalCode: | 996541352 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9074144392 | ||||||||
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| Practice Location | |||||||||
| Address1: | 3190 E MERIDIAN PARK LOOP STE 206A | ||||||||
| Address2: | |||||||||
| City: | WASILLA | ||||||||
| State: | AK | ||||||||
| PostalCode: | 996547422 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9073739462 | ||||||||
| FaxNumber: | 9073739463 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/20/2018 | ||||||||
| LastUpdateDate: | 08/20/2018 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225200000X | 116806 | AK | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapy Assistant |
No ID Information.