Provider Demographics
NPI:1831799758
Name:JIMENEZ, MARIAH DESTINI-RAE
Entity type:Individual
Prefix:
First Name:MARIAH
Middle Name:DESTINI-RAE
Last Name:JIMENEZ
Suffix:
Gender:F
Credentials:
Other - Prefix:MS
Other - First Name:MARIAH
Other - Middle Name:DESTINI-RAE
Other - Last Name:LUJAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:5420 TERRITORIAL RD NW
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87120-2941
Mailing Address - Country:US
Mailing Address - Phone:505-319-4168
Mailing Address - Fax:
Practice Address - Street 1:1217 1ST ST NW
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87102-1529
Practice Address - Country:US
Practice Address - Phone:505-766-5197
Practice Address - Fax:505-312-4046
Is Sole Proprietor?:No
Enumeration Date:2020-10-29
Last Update Date:2025-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM101Y00000X
171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
No101Y00000XBehavioral Health & Social Service ProvidersCounselor