Healthcare Provider Details

I. General information

NPI: 1487942199
Provider Name (Legal Business Name): JIM C. TAYLOR BCBA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/14/2011
Last Update Date: 10/02/2023
Certification Date: 10/02/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

24 JOE KENNEDY BLVD STE 13
STATESBORO GA
30458-3113
US

IV. Provider business mailing address

PO BOX 663
LAKELAND MI
48143-0663
US

V. Phone/Fax

Practice location:
  • Phone: 912-208-2024
  • Fax:
Mailing address:
  • Phone: 734-203-0181
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number1-11-9052
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: