Provider Demographics
NPI:1336260256
Name:LIVESAY, JIMMIE R (BCBA)
Entity Type:Individual
Prefix:MR
First Name:JIMMIE
Middle Name:R
Last Name:LIVESAY
Suffix:
Gender:M
Credentials:BCBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:514 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:JONESBORO
Mailing Address - State:IL
Mailing Address - Zip Code:62952-1800
Mailing Address - Country:US
Mailing Address - Phone:618-614-4265
Mailing Address - Fax:
Practice Address - Street 1:514 N MAIN ST
Practice Address - Street 2:
Practice Address - City:JONESBORO
Practice Address - State:IL
Practice Address - Zip Code:62952-1800
Practice Address - Country:US
Practice Address - Phone:618-614-4265
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TM1800XBehavioral Health & Social Service ProvidersPsychologistIntellectual & Developmental Disabilities