Provider Demographics
NPI:1992892467
Name:JIMENEZ, GEORGIA SUE (LSCSW)
Entity type:Individual
Prefix:
First Name:GEORGIA
Middle Name:SUE
Last Name:JIMENEZ
Suffix:
Gender:F
Credentials:LSCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4103 N TARA CIR
Mailing Address - Street 2:
Mailing Address - City:WICHITA
Mailing Address - State:KS
Mailing Address - Zip Code:67226-3302
Mailing Address - Country:US
Mailing Address - Phone:316-634-6480
Mailing Address - Fax:
Practice Address - Street 1:415 N POPLAR AVE
Practice Address - Street 2:
Practice Address - City:WICHITA
Practice Address - State:KS
Practice Address - Zip Code:67214-4529
Practice Address - Country:US
Practice Address - Phone:316-686-6671
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS2396101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health