Healthcare Provider Details

I. General information

NPI: 1710575303
Provider Name (Legal Business Name): PRISCILLA JIMENEZ PMHNP-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/08/2021
Last Update Date: 01/23/2022
Certification Date: 01/23/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

710 KENMOOR AVE SE STE 100
GRAND RAPIDS MI
49546-2379
US

IV. Provider business mailing address

710 KENMOOR AVE SE STE 100
GRAND RAPIDS MI
49546-2379
US

V. Phone/Fax

Practice location:
  • Phone: 586-944-5827
  • Fax:
Mailing address:
  • Phone: 617-379-0434
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number4704230272NSA200YP
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: