Healthcare Provider Details

I. General information

NPI: 1093221012
Provider Name (Legal Business Name): LILLIAN R JIMENEZ
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/28/2017
Last Update Date: 03/19/2026
Certification Date: 03/19/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

390 CALLE DE ALEGRA STE C
LAS CRUCES NM
88005-3280
US

IV. Provider business mailing address

3100 OAK ST
LAS CRUCES NM
88005-3769
US

V. Phone/Fax

Practice location:
  • Phone: 575-222-4588
  • Fax:
Mailing address:
  • Phone: 575-523-2288
  • Fax: 575-523-2299

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberCCMH0217771
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: