Healthcare Provider Details

I. General information

NPI: 1649761123
Provider Name (Legal Business Name): RAELYNN JIMENEZ
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/21/2018
Last Update Date: 05/22/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2020 RAYBROOK ST SE
GRAND RAPIDS MI
49546
US

IV. Provider business mailing address

2020 RAYBROOK ST SE
GRAND RAPIDS MI
49546-7717
US

V. Phone/Fax

Practice location:
  • Phone: 616-202-4444
  • Fax: 517-323-9531
Mailing address:
  • Phone: 616-202-4444
  • Fax: 517-323-9531

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number6401016655
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: