Provider Demographics
NPI:1124032131
Name:HOWARD, JIM (DBA)
Entity Type:Individual
Prefix:
First Name:JIM
Middle Name:
Last Name:HOWARD
Suffix:
Gender:M
Credentials:DBA
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 1194
Mailing Address - Street 2:
Mailing Address - City:BUCKEYE
Mailing Address - State:AZ
Mailing Address - Zip Code:85326-0088
Mailing Address - Country:US
Mailing Address - Phone:623-691-6904
Mailing Address - Fax:
Practice Address - Street 1:235 W WESTERN AVE
Practice Address - Street 2:
Practice Address - City:AVONDALE
Practice Address - State:AZ
Practice Address - Zip Code:85323-1848
Practice Address - Country:US
Practice Address - Phone:623-772-5000
Practice Address - Fax:623-772-5090
Is Sole Proprietor?:No
Enumeration Date:2006-07-27
Last Update Date:2007-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ895550Medicare UPIN