Provider Demographics
NPI:1518694132
Name:JIMENEZ, MIRELLA (CM61306007)
Entity Type:Individual
Prefix:
First Name:MIRELLA
Middle Name:
Last Name:JIMENEZ
Suffix:
Gender:F
Credentials:CM61306007
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3300 ROOSEVELT AVE
Mailing Address - Street 2:
Mailing Address - City:YAKIMA
Mailing Address - State:WA
Mailing Address - Zip Code:98902-6344
Mailing Address - Country:US
Mailing Address - Phone:509-571-1455
Mailing Address - Fax:
Practice Address - Street 1:3300 ROOSEVELT AVE
Practice Address - Street 2:
Practice Address - City:YAKIMA
Practice Address - State:WA
Practice Address - Zip Code:98902-6344
Practice Address - Country:US
Practice Address - Phone:509-571-1455
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-08-03
Last Update Date:2022-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes247000000XTechnologists, Technicians & Other Technical Service ProvidersTechnician, Health Information
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA910755984Medicaid