Provider Demographics
NPI:1447681960
Name:JIMENEZ, JACQUELINE (LCSW)
Entity type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:
Last Name:JIMENEZ
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:515 WENTWORTH CT
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30215-7833
Mailing Address - Country:US
Mailing Address - Phone:312-504-8523
Mailing Address - Fax:
Practice Address - Street 1:111 PETROL PT
Practice Address - Street 2:SUITE H
Practice Address - City:PEACHTREE CITY
Practice Address - State:GA
Practice Address - Zip Code:30269-1550
Practice Address - Country:US
Practice Address - Phone:312-504-8523
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-12-09
Last Update Date:2013-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL149.0105211041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical