Provider Demographics
NPI:1699814236
Name:HOM, JIM (PHD)
Entity Type:Individual
Prefix:
First Name:JIM
Middle Name:
Last Name:HOM
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 1:9400 N CENTRAL EXPY
Mailing Address - Street 2:STE 904
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75231-5027
Mailing Address - Country:US
Mailing Address - Phone:214-373-3607
Mailing Address - Fax:
Practice Address - Street 1:9400 N CENTRAL EXPY
Practice Address - Street 2:STE 904
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75231-5027
Practice Address - Country:US
Practice Address - Phone:214-373-3607
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-02-06
Last Update Date:2008-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX2-2612103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX81304PMedicare PIN