Provider Demographics
NPI:1114074580
Name:JIMENEZ, CARMEN J (LCSW)
Entity Type:Individual
Prefix:MS
First Name:CARMEN
Middle Name:J
Last Name:JIMENEZ
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10501 34TH AVENUE
Mailing Address - Street 2:
Mailing Address - City:CORONA
Mailing Address - State:NY
Mailing Address - Zip Code:11368-1109
Mailing Address - Country:US
Mailing Address - Phone:718-458-7818
Mailing Address - Fax:718-458-7818
Practice Address - Street 1:10501 34TH AVENUE
Practice Address - Street 2:
Practice Address - City:CORONA
Practice Address - State:NY
Practice Address - Zip Code:11368-1109
Practice Address - Country:US
Practice Address - Phone:718-458-7818
Practice Address - Fax:718-458-7818
Is Sole Proprietor?:No
Enumeration Date:2007-01-05
Last Update Date:2022-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYR0367271104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02265341Medicaid
P50827Medicare UPIN
NYN2Y141Medicare ID - Type Unspecified