Provider Demographics
NPI:1396839544
Name:JIMENEZ, CARLEEN S (LPC)
Entity Type:Individual
Prefix:MS
First Name:CARLEEN
Middle Name:S
Last Name:JIMENEZ
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:164 N ST
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84103-3881
Mailing Address - Country:US
Mailing Address - Phone:801-539-8475
Mailing Address - Fax:
Practice Address - Street 1:2001 S STATE ST
Practice Address - Street 2:SUITE 2300
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84190-2250
Practice Address - Country:US
Practice Address - Phone:801-468-2022
Practice Address - Fax:801-468-2006
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT345654-6004261QR0405X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0405XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation, Substance Use Disorder