Healthcare Provider Details

I. General information

NPI: 1366352049
Provider Name (Legal Business Name): AMANDA JIMENEZ SYLLA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/08/2026
Last Update Date: 09/08/2026
Certification Date: 09/08/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1706 11TH AVE S
SAINT CLOUD MN
56301-5640
US

IV. Provider business mailing address

1706 11TH AVE S
SAINT CLOUD MN
56301-5640
US

V. Phone/Fax

Practice location:
  • Phone: 651-332-3068
  • Fax:
Mailing address:
  • Phone: 651-332-3068
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number24059
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: