Provider Demographics
NPI:1588445621
Name:JIMENEZ, ADELLA RUTH (MSW)
Entity type:Individual
Prefix:
First Name:ADELLA
Middle Name:RUTH
Last Name:JIMENEZ
Suffix:
Gender:F
Credentials:MSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:458 BUENA MESA DR
Mailing Address - Street 2:
Mailing Address - City:CALIMESA
Mailing Address - State:CA
Mailing Address - Zip Code:92320-2133
Mailing Address - Country:US
Mailing Address - Phone:951-609-7178
Mailing Address - Fax:
Practice Address - Street 1:21935 VAN BUREN ST
Practice Address - Street 2:
Practice Address - City:GRAND TERRACE
Practice Address - State:CA
Practice Address - Zip Code:92313-5652
Practice Address - Country:US
Practice Address - Phone:909-906-1023
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-10-12
Last Update Date:2023-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA1172451041C0700X
225400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225400000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRehabilitation Practitioner
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical