Provider Demographics
NPI:1740996313
Name:JIMENEZ, TERESA (CG60621406)
Entity type:Individual
Prefix:
First Name:TERESA
Middle Name:
Last Name:JIMENEZ
Suffix:
Gender:F
Credentials:CG60621406
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1146
Mailing Address - Street 2:
Mailing Address - City:KENT
Mailing Address - State:WA
Mailing Address - Zip Code:98035-1146
Mailing Address - Country:US
Mailing Address - Phone:206-602-8288
Mailing Address - Fax:
Practice Address - Street 1:707 S GRADY WAY STE 600
Practice Address - Street 2:
Practice Address - City:RENTON
Practice Address - State:WA
Practice Address - Zip Code:98057-3227
Practice Address - Country:US
Practice Address - Phone:360-818-4203
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-01-26
Last Update Date:2025-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101Y00000X
WACO61481911101YA0400X
WACG60621406101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)