Provider Demographics
NPI:1639317878
Name:MIMS, JACQUELINE (LPC)
Entity Type:Individual
Prefix:DR
First Name:JACQUELINE
Middle Name:
Last Name:MIMS
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1733 WOODDALE BLVD
Mailing Address - Street 2:
Mailing Address - City:BATON ROUGE
Mailing Address - State:LA
Mailing Address - Zip Code:70806-1508
Mailing Address - Country:US
Mailing Address - Phone:225-924-2800
Mailing Address - Fax:225-924-2800
Practice Address - Street 1:1733 WOODDALE BLVD
Practice Address - Street 2:
Practice Address - City:BATON ROUGE
Practice Address - State:LA
Practice Address - Zip Code:70806-1508
Practice Address - Country:US
Practice Address - Phone:225-924-2800
Practice Address - Fax:225-924-2800
Is Sole Proprietor?:Yes
Enumeration Date:2009-01-27
Last Update Date:2015-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA3676101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health