Provider Demographics
NPI:1386048767
Name:MIXON, JERRY (MS BCBA)
Entity type:Individual
Prefix:MR
First Name:JERRY
Middle Name:
Last Name:MIXON
Suffix:
Gender:M
Credentials:MS BCBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:630 BJ MIXON RD
Mailing Address - Street 2:
Mailing Address - City:COTTONWOOD
Mailing Address - State:AL
Mailing Address - Zip Code:36320-5012
Mailing Address - Country:US
Mailing Address - Phone:334-618-4963
Mailing Address - Fax:
Practice Address - Street 1:630 BJ MIXON RD
Practice Address - Street 2:
Practice Address - City:COTTONWOOD
Practice Address - State:AL
Practice Address - Zip Code:36320-5012
Practice Address - Country:US
Practice Address - Phone:334-618-4963
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-10-14
Last Update Date:2014-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL1-02-0822103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst