Provider Demographics
NPI:1598236440
Name:JIMENEZ IRAHETA, OSCAR ALFREDO (BCBA)
Entity type:Individual
Prefix:
First Name:OSCAR
Middle Name:ALFREDO
Last Name:JIMENEZ IRAHETA
Suffix:
Gender:M
Credentials:BCBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6914 BRISBANE CT STE 200
Mailing Address - Street 2:
Mailing Address - City:SUGAR LAND
Mailing Address - State:TX
Mailing Address - Zip Code:77479-4924
Mailing Address - Country:US
Mailing Address - Phone:346-200-5618
Mailing Address - Fax:
Practice Address - Street 1:12606 GREENVILLE AVE STE 260
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75243-1921
Practice Address - Country:US
Practice Address - Phone:346-200-5618
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-12-17
Last Update Date:2024-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL103K00000X
FLBACB454134106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL103590500Medicaid