Provider Demographics
NPI:1649761123
Name:JIMENEZ, RAELYNN
Entity Type:Individual
Prefix:
First Name:RAELYNN
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 1:2020 RAYBROOK ST SE
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49546-7717
Mailing Address - Country:US
Mailing Address - Phone:616-202-4444
Mailing Address - Fax:517-323-9531
Practice Address - Street 1:2020 RAYBROOK ST SE
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49546
Practice Address - Country:US
Practice Address - Phone:616-202-4444
Practice Address - Fax:517-323-9531
Is Sole Proprietor?:Yes
Enumeration Date:2018-05-21
Last Update Date:2018-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6401016655101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional