=====================================================
General NPI Number Information
=====================================================
NPI Number | 1255705380
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JIMMY DAVIS LCDC, LCPC, CFC
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/01/2015
-----------------------------------------------------
Last Update Date | 07/18/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 367 WATERFRONT ROW
-----------------------------------------------------
City | QUITMAN
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75783-3558
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 214-463-8142
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 367 WATERFRONT ROW
-----------------------------------------------------
City | QUITMAN
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75783-3558
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 214-463-8142
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YA0400X
-----------------------------------------------------
Taxonomy Name | Addiction (Substance Use Disorder) Counselor
-----------------------------------------------------
License Number | 6594
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 101YP1600X
-----------------------------------------------------
Taxonomy Name | Pastoral Counselor
-----------------------------------------------------
License Number | 7347688
-----------------------------------------------------
License Number State | PA
-----------------------------------------------------