Healthcare Provider Details

I. General information

NPI: 1760639900
Provider Name (Legal Business Name): JEANINE MICHELLE WIMBERLY MFT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/19/2008
Last Update Date: 08/31/2025
Certification Date: 08/31/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1901 S JONES BLVD
LAS VEGAS NV
89146-1260
US

IV. Provider business mailing address

1901 S JONES BLVD
LAS VEGAS NV
89146-1260
US

V. Phone/Fax

Practice location:
  • Phone: 702-486-0000
  • Fax: 702-486-7759
Mailing address:
  • Phone: 702-486-0000
  • Fax: 702-486-7759

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number1023
License Number StateNV
# 2
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number0860
License Number StateNV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: