Healthcare Provider Details

I. General information

NPI: 1669139119
Provider Name (Legal Business Name): JDA AUTISM CENTER #1
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/19/2021
Last Update Date: 11/19/2021
Certification Date: 11/19/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

23221 ALDINE WESTFIELD RD STE 200
SPRING TX
77373-7755
US

IV. Provider business mailing address

12818 WINDING MANOR DR
HOUSTON TX
77044-6029
US

V. Phone/Fax

Practice location:
  • Phone: 832-573-6199
  • Fax:
Mailing address:
  • Phone: 832-573-6199
  • 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 Code261QH0700X
TaxonomyHearing and Speech Clinic/Center
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code261QP2000X
TaxonomyPhysical Therapy Clinic/Center
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code261QX0100X
TaxonomyOccupational Medicine Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MIKAEL DWAYNE SIMPSON
Title or Position: OWNER
Credential:
Phone: 832-573-6199