Provider Demographics
NPI:1255705380
Name:DAVIS, JIMMY (LCDC, LCPC, CFC)
Entity type:Individual
Prefix:DR
First Name:JIMMY
Middle Name:
Last Name:DAVIS
Suffix:
Gender:M
Credentials:LCDC, LCPC, CFC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:367 WATERFRONT ROW
Mailing Address - Street 2:
Mailing Address - City:QUITMAN
Mailing Address - State:TX
Mailing Address - Zip Code:75783-3558
Mailing Address - Country:US
Mailing Address - Phone:214-463-8142
Mailing Address - Fax:
Practice Address - Street 1:367 WATERFRONT ROW
Practice Address - Street 2:
Practice Address - City:QUITMAN
Practice Address - State:TX
Practice Address - Zip Code:75783-3558
Practice Address - Country:US
Practice Address - Phone:214-463-8142
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-12-01
Last Update Date:2016-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX6594101YA0400X
PA7347688101YP1600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No101YP1600XBehavioral Health & Social Service ProvidersCounselorPastoral