Provider Demographics
NPI:1275928228
Name:CHAMBERLAIN, JIMMY ALPHONSE
Entity type:Individual
Prefix:
First Name:JIMMY
Middle Name:ALPHONSE
Last Name:CHAMBERLAIN
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 1:5015 RUSTIC OAK DR
Mailing Address - Street 2:
Mailing Address - City:LONGVIEW
Mailing Address - State:TX
Mailing Address - Zip Code:75604-8202
Mailing Address - Country:US
Mailing Address - Phone:903-445-4064
Mailing Address - Fax:
Practice Address - Street 1:5015 RUSTIC OAK DR
Practice Address - Street 2:
Practice Address - City:LONGVIEW
Practice Address - State:TX
Practice Address - Zip Code:75604-8202
Practice Address - Country:US
Practice Address - Phone:903-445-4064
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-04-06
Last Update Date:2024-12-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX116665225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist