=====================================================
General NPI Number Information
=====================================================
NPI Number | 1427337195
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | PAULA ANDREA JIMENEZ
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/11/2011
-----------------------------------------------------
Last Update Date | 06/04/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3600 W FULLERTON AVE
-----------------------------------------------------
City | CHICAGO
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60647-2319
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 773-782-2800
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3600 W FULLERTON AVE
-----------------------------------------------------
City | CHICAGO
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60647-2319
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 773-782-2800
-----------------------------------------------------
Fax | 773-782-5042
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YP2500X
-----------------------------------------------------
Taxonomy Name | Professional Counselor
-----------------------------------------------------
License Number | 180012933
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 103K00000X
-----------------------------------------------------
Taxonomy Name | Behavior Analyst
-----------------------------------------------------
License Number | 263083308
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------