Provider Demographics
NPI:1316643885
Name:JIMENEZ TIRADO, JOSE V (CLSW)
Entity type:Individual
Prefix:
First Name:JOSE
Middle Name:V
Last Name:JIMENEZ TIRADO
Suffix:
Gender:M
Credentials:CLSW
Other - Prefix:MR
Other - First Name:JOSE
Other - Middle Name:V
Other - Last Name:JIMENEZ TIRADO
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:CLSW
Mailing Address - Street 1:HC 10 BOX 49467
Mailing Address - Street 2:
Mailing Address - City:CAGUAS
Mailing Address - State:PR
Mailing Address - Zip Code:00725-9605
Mailing Address - Country:US
Mailing Address - Phone:939-239-6995
Mailing Address - Fax:
Practice Address - Street 1:URB.JOSE DELGADO E11 CALLE 7
Practice Address - Street 2:
Practice Address - City:CAGUAS
Practice Address - State:PR
Practice Address - Zip Code:00725-0072
Practice Address - Country:US
Practice Address - Phone:939-239-6995
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-02-06
Last Update Date:2023-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR161221041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
PR16122Medicaid