Provider Demographics
NPI:1407152168
Name:JIMENEZ, RICACHA (CASE MANAGER)
Entity Type:Individual
Prefix:
First Name:RICACHA
Middle Name:
Last Name:JIMENEZ
Suffix:
Gender:F
Credentials:CASE MANAGER
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:402 E MAIN ST
Mailing Address - Street 2:
Mailing Address - City:WATERBURY
Mailing Address - State:CT
Mailing Address - Zip Code:06702-1701
Mailing Address - Country:US
Mailing Address - Phone:203-755-1143
Mailing Address - Fax:203-755-1447
Practice Address - Street 1:402 E MAIN ST
Practice Address - Street 2:
Practice Address - City:WATERBURY
Practice Address - State:CT
Practice Address - Zip Code:06702-1701
Practice Address - Country:US
Practice Address - Phone:203-755-1143
Practice Address - Fax:203-755-1447
Is Sole Proprietor?:No
Enumeration Date:2011-01-28
Last Update Date:2021-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101Y00000X
CT171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
No171M00000XOther Service ProvidersCase Manager/Care Coordinator