Provider Demographics
NPI:1275260838
Name:JIMENEZ, ADOLFO (CADC-R/QMHP-R)
Entity Type:Individual
Prefix:
First Name:ADOLFO
Middle Name:
Last Name:JIMENEZ
Suffix:
Gender:M
Credentials:CADC-R/QMHP-R
Other - Prefix:
Other - First Name:ADOLFO ALBERTO
Other - Middle Name:
Other - Last Name:JIMENEZ SANCHEZ
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:CADC-R/QMHP-R
Mailing Address - Street 1:421 SW OAK ST STE 520
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97204-1810
Mailing Address - Country:US
Mailing Address - Phone:503-988-5887
Mailing Address - Fax:
Practice Address - Street 1:421 SW OAK ST STE 520
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97204-1810
Practice Address - Country:US
Practice Address - Phone:503-988-5887
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-08-03
Last Update Date:2023-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORT-22-1890101YA0400X
ORA13640104100000X
OR22-QMHP-R-1481101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR500809625Medicaid