Provider Demographics
NPI:1679361893
Name:DAVIS, JIM DYLAN (CAPRC, CPSP)
Entity type:Individual
Prefix:
First Name:JIM
Middle Name:DYLAN
Last Name:DAVIS
Suffix:
Gender:M
Credentials:CAPRC, CPSP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:531 DUROC CT APT A
Mailing Address - Street 2:
Mailing Address - City:LAFAYETTE
Mailing Address - State:IN
Mailing Address - Zip Code:47909-6779
Mailing Address - Country:US
Mailing Address - Phone:812-508-2980
Mailing Address - Fax:
Practice Address - Street 1:914 SOUTH ST
Practice Address - Street 2:
Practice Address - City:LAFAYETTE
Practice Address - State:IN
Practice Address - Zip Code:47901-1416
Practice Address - Country:US
Practice Address - Phone:765-742-1088
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-04-28
Last Update Date:2025-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN175T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist