Provider Demographics
NPI:1174105001
Name:WHITE, JIM E (MED, RBT)
Entity type:Individual
Prefix:
First Name:JIM
Middle Name:E
Last Name:WHITE
Suffix:
Gender:M
Credentials:MED, RBT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:400 INTEGRA DUNES CIR APT 210
Mailing Address - Street 2:
Mailing Address - City:DELAND
Mailing Address - State:FL
Mailing Address - Zip Code:32724-8644
Mailing Address - Country:US
Mailing Address - Phone:386-235-2453
Mailing Address - Fax:
Practice Address - Street 1:400 INTEGRA DUNES CIR APT 210
Practice Address - Street 2:
Practice Address - City:DELAND
Practice Address - State:FL
Practice Address - Zip Code:32724-8644
Practice Address - Country:US
Practice Address - Phone:386-235-2453
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-04-21
Last Update Date:2021-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRBT-20-138039106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician