Provider Demographics
NPI:1164114237
Name:JAMISON, KOBE M (BA, RBT)
Entity type:Individual
Prefix:
First Name:KOBE
Middle Name:M
Last Name:JAMISON
Suffix:
Gender:M
Credentials:BA, RBT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15116 N COTTON LN
Mailing Address - Street 2:
Mailing Address - City:SURPRISE
Mailing Address - State:AZ
Mailing Address - Zip Code:85388-9618
Mailing Address - Country:US
Mailing Address - Phone:623-259-9819
Mailing Address - Fax:317-520-8200
Practice Address - Street 1:1585 N 113TH AVE STE 102
Practice Address - Street 2:
Practice Address - City:AVONDALE
Practice Address - State:AZ
Practice Address - Zip Code:85392-3938
Practice Address - Country:US
Practice Address - Phone:623-259-9819
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-05-25
Last Update Date:2024-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RBT-22-224914106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician