Provider Demographics
NPI:1891529996
Name:JIMENEZ, TRICIA L (MA, LAC)
Entity type:Individual
Prefix:
First Name:TRICIA
Middle Name:L
Last Name:JIMENEZ
Suffix:
Gender:F
Credentials:MA, LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:25223 N 73RD LN
Mailing Address - Street 2:
Mailing Address - City:PEORIA
Mailing Address - State:AZ
Mailing Address - Zip Code:85383-7230
Mailing Address - Country:US
Mailing Address - Phone:602-577-9111
Mailing Address - Fax:
Practice Address - Street 1:17431 N 71ST DR STE 103
Practice Address - Street 2:
Practice Address - City:GLENDALE
Practice Address - State:AZ
Practice Address - Zip Code:85308-8598
Practice Address - Country:US
Practice Address - Phone:602-633-2246
Practice Address - Fax:602-687-7069
Is Sole Proprietor?:Yes
Enumeration Date:2024-08-29
Last Update Date:2024-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ20297101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health