Provider Demographics
NPI:1326879743
Name:JIMENEZ VENOSA, ANDREA
Entity type:Individual
Prefix:
First Name:ANDREA
Middle Name:
Last Name:JIMENEZ VENOSA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6812 DEVINNEY LN
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46221-4650
Mailing Address - Country:US
Mailing Address - Phone:317-777-5870
Mailing Address - Fax:
Practice Address - Street 1:125 N SHORTRIDGE RD
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46219-4908
Practice Address - Country:US
Practice Address - Phone:317-241-4673
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-08-08
Last Update Date:2024-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health