MEDICARE: JESSICA KHAIMOV

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	103K00000X	Behavior Analyst

General Provider Information

NPI Number	:	1427629666
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JESSICA KHAIMOV

Provider Business Mailing Address
First Line	:	6259 108TH ST APT 7K
Second Line	:
City	:	FOREST HILLS
State	:	NY
Zip	:	11375-1327
Country	:	US
Telephone Number	:	917-476-5384
Fax Number	:

Provider Business Practice Location Address
First Line	:	6259 108TH ST APT 7K
Second Line	:
City	:	FOREST HILLS
State	:	NY
Zip	:	11375-1327
Country	:	US
Telephone Number	:	917-476-5384
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/08/2021
Last Update Date	:	07/08/2021

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