Provider Demographics
NPI:1760639900
Name:WIMBERLY, JEANINE MICHELLE (MFT)
Entity Type:Individual
Prefix:MS
First Name:JEANINE
Middle Name:MICHELLE
Last Name:WIMBERLY
Suffix:
Gender:F
Credentials:MFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6171 W CHARLESTON BLVD
Mailing Address - Street 2:D
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89146-1126
Mailing Address - Country:US
Mailing Address - Phone:702-486-0000
Mailing Address - Fax:702-486-7759
Practice Address - Street 1:6171 W CHARLESTON BLVD
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89146-1126
Practice Address - Country:US
Practice Address - Phone:702-486-0000
Practice Address - Fax:702-486-7759
Is Sole Proprietor?:Yes
Enumeration Date:2008-08-19
Last Update Date:2013-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV1023101YA0400X
NV0860106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)