Basic Information
| Provider Information | |||||||||
| NPI: | 1518053602 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | JIMENEZ | ||||||||
| FirstName: | DARLENE | ||||||||
| MiddleName: | DOROTHEA | ||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | LPC RNC LCDC | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | MAYO | ||||||||
| OtherFirstName: | DARLENE | ||||||||
| OtherMiddleName: | DOROTHEA | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 3031 W IH 10 | ||||||||
| Address2: | |||||||||
| City: | SAN ANTONIO | ||||||||
| State: | TX | ||||||||
| PostalCode: | 782015159 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2102611000 | ||||||||
| FaxNumber: | 2107318678 | ||||||||
| Practice Location | |||||||||
| Address1: | 3031 W IH 10 | ||||||||
| Address2: | |||||||||
| City: | SAN ANTONIO | ||||||||
| State: | TX | ||||||||
| PostalCode: | 782015159 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2102611000 | ||||||||
| FaxNumber: | 2107318678 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/05/2006 | ||||||||
| LastUpdateDate: | 02/09/2016 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X | 5412 | TX | N | Behavioral Health & Social Service Providers | Counselor | Mental Health | 101YP2500X | 13092 | TX | Y | Behavioral Health & Social Service Providers | Counselor | Professional | 163W00000X | 447244 | TX | N | Nursing Service Providers | Registered Nurse |
ID Information
| ID | Type | State | Issuer | Description | 026955701 | 05 | TX | MEDICAID |