Provider Demographics
NPI:1215280904
Name:JIMENEZ, CARMEN KADESHA (MSW, LCSW, LISW-CP)
Entity type:Individual
Prefix:
First Name:CARMEN
Middle Name:KADESHA
Last Name:JIMENEZ
Suffix:
Gender:F
Credentials:MSW, LCSW, LISW-CP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 5111
Mailing Address - Street 2:
Mailing Address - City:AUGUSTA
Mailing Address - State:GA
Mailing Address - Zip Code:30916-5111
Mailing Address - Country:US
Mailing Address - Phone:980-275-2505
Mailing Address - Fax:207-591-9801
Practice Address - Street 1:4460 WASHINGTON RD STE 19
Practice Address - Street 2:
Practice Address - City:EVANS
Practice Address - State:GA
Practice Address - Zip Code:30809-3963
Practice Address - Country:US
Practice Address - Phone:980-275-2505
Practice Address - Fax:207-591-9801
Is Sole Proprietor?:Yes
Enumeration Date:2012-10-18
Last Update Date:2019-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SCSW.10478 CP101YM0800X, 1041C0700X
NCP007687101YM0800X, 1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA003213277AMedicaid
SCSW1128Medicaid