Provider Demographics
NPI:1093164154
Name:JIMENEZ, ABRAHAM
Entity Type:Individual
Prefix:
First Name:ABRAHAM
Middle Name:
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 1:721 N. LASALLE STREET
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60654
Mailing Address - Country:US
Mailing Address - Phone:708-329-4064
Mailing Address - Fax:708-460-0502
Practice Address - Street 1:721 N. LASALLE STREET
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60654
Practice Address - Country:US
Practice Address - Phone:708-329-4064
Practice Address - Fax:708-460-0502
Is Sole Proprietor?:No
Enumeration Date:2016-06-09
Last Update Date:2016-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor