Provider Demographics
NPI:1356558688
Name:MENDEZ, JAIME (LICSW)
Entity type:Individual
Prefix:MR
First Name:JAIME
Middle Name:
Last Name:MENDEZ
Suffix:
Gender:M
Credentials:LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:24 ANNETTE AVE
Mailing Address - Street 2:
Mailing Address - City:PAWTUCKET
Mailing Address - State:RI
Mailing Address - Zip Code:02861-4418
Mailing Address - Country:US
Mailing Address - Phone:401-640-3917
Mailing Address - Fax:401-525-2557
Practice Address - Street 1:830 CHALKSTONE AVE
Practice Address - Street 2:TRAILER 36
Practice Address - City:PROVIDENCE
Practice Address - State:RI
Practice Address - Zip Code:02908-4734
Practice Address - Country:US
Practice Address - Phone:401-640-3917
Practice Address - Fax:401-525-2557
Is Sole Proprietor?:No
Enumeration Date:2007-05-17
Last Update Date:2016-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RIISW020301041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
RIJM66771Medicaid