Provider Demographics
NPI:1417658469
Name:WARREN, JIMMIE
Entity Type:Individual
Prefix:
First Name:JIMMIE
Middle Name:
Last Name:WARREN
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 1:53 PRAIRIE AVE
Mailing Address - Street 2:
Mailing Address - City:SUFFERN
Mailing Address - State:NY
Mailing Address - Zip Code:10901-6232
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:53 PRAIRIE AVE
Practice Address - Street 2:
Practice Address - City:SUFFERN
Practice Address - State:NY
Practice Address - Zip Code:10901-6232
Practice Address - Country:US
Practice Address - Phone:845-641-1785
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-03-16
Last Update Date:2023-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst