Healthcare Provider Details

I. General information

NPI: 1558146035
Provider Name (Legal Business Name): SARA JIMENEZ
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: SARA STARK

II. Dates (important events)

Enumeration Date: 08/31/2023
Last Update Date: 12/09/2024
Certification Date: 12/09/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

511 PERRY ST
DEFIANCE OH
43512-2123
US

IV. Provider business mailing address

511 PERRY ST
DEFIANCE OH
43512-2123
US

V. Phone/Fax

Practice location:
  • Phone: 419-782-9920
  • Fax:
Mailing address:
  • Phone: 419-782-9920
  • Fax: 419-784-2523

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License NumberS.2411505
License Number StateOH
# 2
Primary TaxonomyN
Taxonomy Code172V00000X
TaxonomyCommunity Health Worker
License Number
License Number StateNULL
# 3
Primary TaxonomyN
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: