Provider Demographics
NPI:1629127345
Name:BRANCH, JIM (PHD)
Entity Type:Individual
Prefix:DR
First Name:JIM
Middle Name:
Last Name:BRANCH
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4319 S RIDGEWOOD AVE
Mailing Address - Street 2:
Mailing Address - City:PORT ORANGE
Mailing Address - State:FL
Mailing Address - Zip Code:32127-4522
Mailing Address - Country:US
Mailing Address - Phone:386-451-5126
Mailing Address - Fax:386-756-7518
Practice Address - Street 1:4319 S RIDGEWOOD AVE
Practice Address - Street 2:
Practice Address - City:PORT ORANGE
Practice Address - State:FL
Practice Address - Zip Code:32127-4522
Practice Address - Country:US
Practice Address - Phone:386-451-5126
Practice Address - Fax:386-756-7518
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSW06071041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLZ1039AMedicare ID - Type UnspecifiedMEDICARE