Provider Demographics
NPI:1083270110
Name:ARTIS, JEFFERY TYLER (MED, BCBA, LBA)
Entity Type:Individual
Prefix:
First Name:JEFFERY
Middle Name:TYLER
Last Name:ARTIS
Suffix:
Gender:M
Credentials:MED, BCBA, LBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 12347
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:MS
Mailing Address - Zip Code:39236-2347
Mailing Address - Country:US
Mailing Address - Phone:601-954-5605
Mailing Address - Fax:601-982-0800
Practice Address - Street 1:2510 LAKELAND TER
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39216-4702
Practice Address - Country:US
Practice Address - Phone:601-982-7827
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-05-14
Last Update Date:2019-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
106S00000X
MS190085103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician