Provider Demographics
NPI:1235809492
Name:MAXIS, JEAN DAVIDSON
Entity Type:Individual
Prefix:
First Name:JEAN DAVIDSON
Middle Name:
Last Name:MAXIS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1167 N BENOIST FARMS RD APT 306
Mailing Address - Street 2:
Mailing Address - City:WEST PALM BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33411-9389
Mailing Address - Country:US
Mailing Address - Phone:561-509-4111
Mailing Address - Fax:
Practice Address - Street 1:8785 SW 165TH AVE STE 104
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33193-5827
Practice Address - Country:US
Practice Address - Phone:561-421-5111
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-09-17
Last Update Date:2024-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
106S00000X
FL103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician