Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 102L00000X | Psychologist | 52911 | MS |
Y | 103T00000X | Psychologist | 52911 | MS |
N | 103G00000X | Clinical Psychologist | 52911 | MS |
N | 103TC0700X | Clinical Psychologist | 52911 | MS |
N | 103TC2200X | Clinical Child & Adolescent Psychologist | 52911 | MS |
NPI | 1104916766 |
---|---|
Provider Name | John Clemmons |
First Address | Hattiesburg, MS 39402-1297 |
Second Address | Hattiesburg, MS 39402-1297 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 13/10/2006 |
Last Update Date | 08/10/2020 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
03051508 | (05) | MS |