Healthcare Provider Details

I. General information

NPI: 1609770668
Provider Name (Legal Business Name): LARA ANDREA JIMENEZ
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/05/2026
Last Update Date: 10/05/2026
Certification Date: 10/05/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12301 MAIN ST
HOUSTON TX
77035-6207
US

IV. Provider business mailing address

3003 SUMMER ST APT 330
HOUSTON TX
77007-4884
US

V. Phone/Fax

Practice location:
  • Phone: 713-275-5400
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number104238
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: