Provider Demographics
NPI:1962018853
Name:PERSINGER, JIM DOW
Entity Type:Individual
Prefix:
First Name:JIM
Middle Name:DOW
Last Name:PERSINGER
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 1:4213 BRIARWOOD DR
Mailing Address - Street 2:
Mailing Address - City:LAWRENCE
Mailing Address - State:KS
Mailing Address - Zip Code:66049-1998
Mailing Address - Country:US
Mailing Address - Phone:620-794-1778
Mailing Address - Fax:
Practice Address - Street 1:1 KELLOGG CIR
Practice Address - Street 2:
Practice Address - City:EMPORIA
Practice Address - State:KS
Practice Address - Zip Code:66801-5415
Practice Address - Country:US
Practice Address - Phone:620-341-5317
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-09-16
Last Update Date:2020-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD36557103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool