Provider Demographics
NPI:1841900529
Name:JIM, MARVIN
Entity type:Individual
Prefix:
First Name:MARVIN
Middle Name:
Last Name:JIM
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 1:11221 N 28TH DR BLDG E
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85029-5615
Mailing Address - Country:US
Mailing Address - Phone:602-997-2223
Mailing Address - Fax:
Practice Address - Street 1:11221 N 28TH DR BLDG E
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85029-5615
Practice Address - Country:US
Practice Address - Phone:602-997-2233
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-12-02
Last Update Date:2022-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist