Provider Demographics
NPI:1851765994
Name:JIMINEZ, TARA HAYNES (MA, LPC)
Entity Type:Individual
Prefix:
First Name:TARA
Middle Name:HAYNES
Last Name:JIMINEZ
Suffix:
Gender:F
Credentials:MA, LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:20 WILLOW POND CT
Mailing Address - Street 2:
Mailing Address - City:ACWORTH
Mailing Address - State:GA
Mailing Address - Zip Code:30101-8603
Mailing Address - Country:US
Mailing Address - Phone:210-861-2257
Mailing Address - Fax:
Practice Address - Street 1:2655 DALLAS HWY SW
Practice Address - Street 2:SUITE 520
Practice Address - City:MARIETTA
Practice Address - State:GA
Practice Address - Zip Code:30064-2597
Practice Address - Country:US
Practice Address - Phone:678-919-1077
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-11-29
Last Update Date:2015-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA008472101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional