Healthcare Provider Details

I. General information

NPI: 1336260256
Provider Name (Legal Business Name): JIMMIE R LIVESAY BCBA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/02/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

514 N MAIN ST
JONESBORO IL
62952-1800
US

IV. Provider business mailing address

514 N MAIN ST
JONESBORO IL
62952-1800
US

V. Phone/Fax

Practice location:
  • Phone: 618-614-4265
  • Fax:
Mailing address:
  • Phone: 618-614-4265
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TM1800X
TaxonomyIntellectual & Developmental Disabilities Psychologist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: