Provider Demographics
NPI:1902402019
Name:JIMENEZ ULLOA, ROSMERY
Entity Type:Individual
Prefix:
First Name:ROSMERY
Middle Name:
Last Name:JIMENEZ ULLOA
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 1:150 E 1ST AVE APT 1415
Mailing Address - Street 2:
Mailing Address - City:HIALEAH
Mailing Address - State:FL
Mailing Address - Zip Code:33010-4961
Mailing Address - Country:US
Mailing Address - Phone:786-296-4367
Mailing Address - Fax:
Practice Address - Street 1:150 E 1ST AVE APT 1415
Practice Address - Street 2:
Practice Address - City:HIALEAH
Practice Address - State:FL
Practice Address - Zip Code:33010-4961
Practice Address - Country:US
Practice Address - Phone:786-296-4367
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-12-05
Last Update Date:2020-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO20-122806106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior TechnicianGroup - Single Specialty