Provider Demographics
NPI:1447092135
Name:JIMENEZ, EMILY M (PHD, LP, NSSP, MED)
Entity type:Individual
Prefix:
First Name:EMILY
Middle Name:M
Last Name:JIMENEZ
Suffix:
Gender:F
Credentials:PHD, LP, NSSP, MED
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1707 MAYFLOWER DR
Mailing Address - Street 2:
Mailing Address - City:CARROLLTON
Mailing Address - State:TX
Mailing Address - Zip Code:75007-3024
Mailing Address - Country:US
Mailing Address - Phone:512-745-0743
Mailing Address - Fax:
Practice Address - Street 1:2727 E SOUTHLAKE BLVD
Practice Address - Street 2:
Practice Address - City:SOUTHLAKE
Practice Address - State:TX
Practice Address - Zip Code:76092-6613
Practice Address - Country:US
Practice Address - Phone:682-885-6000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-06-12
Last Update Date:2024-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX39846103G00000X, 103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103G00000XBehavioral Health & Social Service ProvidersClinical Neuropsychologist