Healthcare Provider Details

I. General information

NPI: 1912636630
Provider Name (Legal Business Name): JIMAC LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/08/2022
Last Update Date: 06/08/2022
Certification Date: 06/08/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10828 W ELM ST
PHOENIX AZ
85037-1091
US

IV. Provider business mailing address

10828 W ELM ST
PHOENIX AZ
85037-1091
US

V. Phone/Fax

Practice location:
  • Phone: 602-561-4951
  • Fax:
Mailing address:
  • Phone: 602-561-4951
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code103TA0400X
TaxonomyAddiction (Substance Use Disorder) Psychologist
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code103TC1900X
TaxonomyCounseling Psychologist
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code106E00000X
TaxonomyAssistant Behavior Analyst
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number State
# 6
Primary TaxonomyN
Taxonomy Code163WA0400X
TaxonomyAddiction (Substance Use Disorder) Registered Nurse
License Number
License Number State

VIII. Authorized Official

Name: JOHN JOHN MARCUS
Title or Position: PROGRAM DIRECTOR
Credential:
Phone: 602-561-4951