Provider Demographics
NPI:1992143507
Name:JIMMERSON, DAVID WAYNE (LAPC)
Entity type:Individual
Prefix:MR
First Name:DAVID
Middle Name:WAYNE
Last Name:JIMMERSON
Suffix:
Gender:M
Credentials:LAPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:130 BLAIR DR
Mailing Address - Street 2:
Mailing Address - City:NORTH AUGUSTA
Mailing Address - State:SC
Mailing Address - Zip Code:29860-9756
Mailing Address - Country:US
Mailing Address - Phone:910-787-6402
Mailing Address - Fax:
Practice Address - Street 1:1 FREEDOM WAY
Practice Address - Street 2:
Practice Address - City:AUGUSTA
Practice Address - State:GA
Practice Address - Zip Code:30904-6258
Practice Address - Country:US
Practice Address - Phone:706-733-0188
Practice Address - Fax:706-481-6798
Is Sole Proprietor?:No
Enumeration Date:2013-06-06
Last Update Date:2013-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAAPC003735101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional