Healthcare Provider Details

I. General information

NPI: 1154241131
Provider Name (Legal Business Name): JAH VON ANTHONY MIMS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/20/2026
Last Update Date: 07/20/2026
Certification Date: 07/19/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2013 MESA DR SE
ATLANTA GA
30316-4915
US

IV. Provider business mailing address

2013 MESA DR SE
ATLANTA GA
30316-4915
US

V. Phone/Fax

Practice location:
  • Phone: 631-308-9448
  • Fax:
Mailing address:
  • Phone: 631-308-9448
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number070111119
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: