Provider Demographics
NPI:1144181280
Name:VASQUEZ, JIMMY
Entity type:Individual
Prefix:
First Name:JIMMY
Middle Name:
Last Name:VASQUEZ
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1620 FM-544 E
Mailing Address - Street 2:SUITE 100
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75287-7023
Mailing Address - Country:US
Mailing Address - Phone:844-272-7223
Mailing Address - Fax:
Practice Address - Street 1:17671 ADDISON RD APT 402
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75287-7023
Practice Address - Country:US
Practice Address - Phone:972-515-1097
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-11-19
Last Update Date:2025-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX41491092106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior TechnicianGroup - Single Specialty