Provider Demographics
NPI:1851937338
Name:JIMENEZ, SHELSEY LEEAN
Entity Type:Individual
Prefix:
First Name:SHELSEY
Middle Name:LEEAN
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 1:85 W BURNSIDE AVE
Mailing Address - Street 2:
Mailing Address - City:BRONX
Mailing Address - State:NY
Mailing Address - Zip Code:10453-4015
Mailing Address - Country:US
Mailing Address - Phone:718-716-4400
Mailing Address - Fax:
Practice Address - Street 1:57-69 W. BURNSIDE AVE
Practice Address - Street 2:BASEMENT LEVEL 1
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10453
Practice Address - Country:US
Practice Address - Phone:718-716-4400
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-11-20
Last Update Date:2024-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY120983-01104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes104100000XBehavioral Health & Social Service ProvidersSocial WorkerGroup - Single Specialty