Provider Demographics
NPI:1730741240
Name:GIDDINGS, JIMMY LAMAR (LBSW)
Entity type:Individual
Prefix:
First Name:JIMMY
Middle Name:LAMAR
Last Name:GIDDINGS
Suffix:
Gender:M
Credentials:LBSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2114 E MARSHALL AVE APT 202
Mailing Address - Street 2:
Mailing Address - City:LONGVIEW
Mailing Address - State:TX
Mailing Address - Zip Code:75601-6900
Mailing Address - Country:US
Mailing Address - Phone:903-431-5309
Mailing Address - Fax:
Practice Address - Street 1:2924 KNIGHT ST STE 436
Practice Address - Street 2:
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71105-2431
Practice Address - Country:US
Practice Address - Phone:318-272-2320
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-07-03
Last Update Date:2019-07-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX21994104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1316398781Medicaid