Provider Demographics
NPI:1558932145
Name:JIMISON, JENIFER
Entity Type:Individual
Prefix:
First Name:JENIFER
Middle Name:
Last Name:JIMISON
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 1:8134 NEW LA GRANGE RD STE 100
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40222-4677
Mailing Address - Country:US
Mailing Address - Phone:502-767-0415
Mailing Address - Fax:
Practice Address - Street 1:8134 NEW LA GRANGE RD STE 100
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40222-4677
Practice Address - Country:US
Practice Address - Phone:502-767-0415
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-07-06
Last Update Date:2023-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY2523671041C0700X
KY2565191041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100750990Medicaid