Healthcare Provider Details

I. General information

NPI: 1578993481
Provider Name (Legal Business Name): MAYDELIN JIMENEZ
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/14/2013
Last Update Date: 06/15/2025
Certification Date: 06/15/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11755 SW 90TH ST
MIAMI FL
33186-2177
US

IV. Provider business mailing address

4570 PHIPPS DR
PORT ORANGE FL
32129-3678
US

V. Phone/Fax

Practice location:
  • Phone: 305-846-9807
  • Fax:
Mailing address:
  • Phone: 786-587-6479
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number25940
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: