Provider Demographics
NPI:1336486927
Name:KIDD, JENEAR WIMBLEY
Entity Type:Individual
Prefix:MRS
First Name:JENEAR
Middle Name:WIMBLEY
Last Name:KIDD
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 1:370 RAYS RD
Mailing Address - Street 2:
Mailing Address - City:STONE MTN
Mailing Address - State:GA
Mailing Address - Zip Code:30083-4216
Mailing Address - Country:US
Mailing Address - Phone:404-465-9132
Mailing Address - Fax:
Practice Address - Street 1:175 GWINNETT DR
Practice Address - Street 2:
Practice Address - City:LAWRENCEVILLE
Practice Address - State:GA
Practice Address - Zip Code:30046-8444
Practice Address - Country:US
Practice Address - Phone:770-339-2395
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-01-15
Last Update Date:2013-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health