Provider Demographics
NPI:1881985091
Name:JIMENEZ, LISSETTE (LSW)
Entity type:Individual
Prefix:MS
First Name:LISSETTE
Middle Name:
Last Name:JIMENEZ
Suffix:
Gender:F
Credentials:LSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1117 N DEARBORN ST
Mailing Address - Street 2:APT 416
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60610-2701
Mailing Address - Country:US
Mailing Address - Phone:317-402-9123
Mailing Address - Fax:
Practice Address - Street 1:4822 N BROADWAY ST
Practice Address - Street 2:2ND FLOOR
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60640-3604
Practice Address - Country:US
Practice Address - Phone:773-429-9287
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-04-21
Last Update Date:2011-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health