Provider Demographics
NPI:1710631577
Name:JIMENEZ, MARY DENISE (LICSW)
Entity Type:Individual
Prefix:MRS
First Name:MARY DENISE
Middle Name:
Last Name:JIMENEZ
Suffix:
Gender:F
Credentials:LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:435 W BELL ST
Mailing Address - Street 2:
Mailing Address - City:SEQUIM
Mailing Address - State:WA
Mailing Address - Zip Code:98382-2916
Mailing Address - Country:US
Mailing Address - Phone:786-303-0441
Mailing Address - Fax:
Practice Address - Street 1:435 W BELL ST
Practice Address - Street 2:
Practice Address - City:SEQUIM
Practice Address - State:WA
Practice Address - Zip Code:98382-2916
Practice Address - Country:US
Practice Address - Phone:786-303-0441
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-02-09
Last Update Date:2022-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WASC612479371041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical