Basic Information
Provider Information
NPI: 1003142860
EntityType: 1
ReplacementNPI:  
OrganizationName:  
LastName: JIMENEZ
FirstName: GLORIA
MiddleName: I
NamePrefix:  
NameSuffix:  
Credential: MA
OtherOrganizationName:  
OtherOrganizationType:  
OtherLastName:  
OtherFirstName:  
OtherMiddleName:  
OtherNamePrefix:  
OtherNameSuffix:  
OtherCredential:  
OtherLastNameType:  
Mailing Information
Address1: 2030 W TILGHMAN ST
Address2: SUITE 105B
City: ALLENTOWN
State: PA
PostalCode: 181044354
CountryCode: US
TelephoneNumber: 4842219136
FaxNumber: 4842219130
Practice Location
Address1: 2152 N FRONT ST
Address2:  
City: PHILADELPHIA
State: PA
PostalCode: 191221705
CountryCode: US
TelephoneNumber: 4842219136
FaxNumber: 4842219130
Other Information
ProviderEnumerationDate: 10/28/2009
LastUpdateDate: 10/28/2009
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode: F
AuthorizedOfficialLastName:  
AuthorizedOfficialFirstName:  
AuthorizedOfficialMiddleName:  
AuthorizedOfficialTitleorPosition:  
AuthorizedOfficialTelephone:  
IsSoleProprietor: N
IsOrganizationSubpart:  
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix:  
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential:  

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
101YM0800X  Y Behavioral Health & Social Service ProvidersCounselorMental Health

No ID Information.


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