Provider Demographics
NPI:1407346778
Name:JIMENEZ, DALISA
Entity Type:Individual
Prefix:
First Name:DALISA
Middle Name:
Last Name:JIMENEZ
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4425 E AGAVE RD STE 106
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85044-0620
Mailing Address - Country:US
Mailing Address - Phone:480-248-5338
Mailing Address - Fax:
Practice Address - Street 1:4425 E AGAVE RD STE 106
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85044-0620
Practice Address - Country:US
Practice Address - Phone:480-248-5338
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-05-13
Last Update Date:2019-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZLPC-17074101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Single Specialty