Provider Demographics
NPI:1134642846
Name:JIMMERSON, SHAQUINA
Entity Type:Individual
Prefix:
First Name:SHAQUINA
Middle Name:
Last Name:JIMMERSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:110 MUSCADINE CT S
Mailing Address - Street 2:
Mailing Address - City:FAIRBURN
Mailing Address - State:GA
Mailing Address - Zip Code:30213-6066
Mailing Address - Country:US
Mailing Address - Phone:770-377-3935
Mailing Address - Fax:
Practice Address - Street 1:1401 PEACHTREE ST NE, SUITE 500
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30213
Practice Address - Country:US
Practice Address - Phone:770-377-3935
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-07-25
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA9703101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional