Healthcare Provider Details

I. General information

NPI: 1366364523
Provider Name (Legal Business Name): GERSON LISANDRO JIMENEZ
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/29/2026
Last Update Date: 07/29/2026
Certification Date: 07/29/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

174 E 23RD ST # 2
PATERSON NJ
07514-2133
US

IV. Provider business mailing address

174 E 23RD ST # 2
PATERSON NJ
07514-2133
US

V. Phone/Fax

Practice location:
  • Phone: 973-720-2000
  • Fax:
Mailing address:
  • Phone: 973-720-2000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number37AC00988900
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: