Healthcare Provider Details

I. General information

NPI: 1073903977
Provider Name (Legal Business Name): GERARDO JIMENEZ
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/29/2015
Last Update Date: 09/14/2026
Certification Date: 09/14/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3000 MARKET ST NE STE 426
SALEM OR
97301-1894
US

IV. Provider business mailing address

4751 SERRA CT NE
SALEM OR
97305-2644
US

V. Phone/Fax

Practice location:
  • Phone: 503-583-3604
  • Fax:
Mailing address:
  • Phone: 503-583-3604
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberL8206
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: