Provider Demographics
NPI:1669517504
Name:JIMENEZ, JOSE L (PSYD)
Entity type:Individual
Prefix:
First Name:JOSE
Middle Name:L
Last Name:JIMENEZ
Suffix:
Gender:M
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1100 W CERMAK RD
Mailing Address - Street 2:SUITE B-305 UNIT 1
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60608-4500
Mailing Address - Country:US
Mailing Address - Phone:773-391-1541
Mailing Address - Fax:
Practice Address - Street 1:1100 W CERMAK RD
Practice Address - Street 2:SUITE B-305 UNIT 1
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60608-4500
Practice Address - Country:US
Practice Address - Phone:773-391-1541
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-20
Last Update Date:2021-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL071007936103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical