Provider Demographics
NPI:1215607171
Name:WATTS, JIMENA AMANDA (LCSWA)
Entity type:Individual
Prefix:
First Name:JIMENA
Middle Name:AMANDA
Last Name:WATTS
Suffix:
Gender:F
Credentials:LCSWA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1315 EAST BLVD UNIT 302
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28203-5978
Mailing Address - Country:US
Mailing Address - Phone:704-770-7814
Mailing Address - Fax:
Practice Address - Street 1:133 STETSON DR
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28262-3326
Practice Address - Country:US
Practice Address - Phone:704-770-7814
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-09-14
Last Update Date:2021-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCP0155011041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical