Healthcare Provider Details

I. General information

NPI: 1831998418
Provider Name (Legal Business Name): RUTH CAROLINA POLO JIMENEZ
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/07/2025
Last Update Date: 03/07/2025
Certification Date: 03/07/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

25028 104TH AVE SE
KENT WA
98030-9310
US

IV. Provider business mailing address

25028 104TH AVE SE
KENT WA
98030-9310
US

V. Phone/Fax

Practice location:
  • Phone: 206-764-8019
  • Fax:
Mailing address:
  • Phone: 206-764-8019
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberCG61597857
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: