Provider Demographics
NPI:1669103073
Name:JIMENEZ MENDEZ, MIGUEL ANGEL (MASTER)
Entity type:Individual
Prefix:MR
First Name:MIGUEL
Middle Name:ANGEL
Last Name:JIMENEZ MENDEZ
Suffix:
Gender:M
Credentials:MASTER
Other - Prefix:
Other - First Name:MIGUEL
Other - Middle Name:A
Other - Last Name:JIMENEZ MENDEZ
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:CLINICAL SOCIAL WORK
Mailing Address - Street 1:SAN RAFAEL #211, BO. SALUD, MAYAGUEZ, P.R.
Mailing Address - Street 2:
Mailing Address - City:MAYAGUEZ
Mailing Address - State:PR
Mailing Address - Zip Code:00680
Mailing Address - Country:US
Mailing Address - Phone:939-641-0818
Mailing Address - Fax:
Practice Address - Street 1:SAN RAFAEL #211, BO. SALUD, MAYAGUEZ, P.R
Practice Address - Street 2:
Practice Address - City:MAYAGUEZ
Practice Address - State:PR
Practice Address - Zip Code:00680
Practice Address - Country:US
Practice Address - Phone:787-951-0230
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-06-17
Last Update Date:2022-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
158001041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
PR0812Other0812