Healthcare Provider Details

I. General information

NPI: 1245521384
Provider Name (Legal Business Name): J. C. MCCLEOD, M.D., PSYCHIATRIC, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/24/2011
Last Update Date: 04/24/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

101 MEDICAL DR
DOTHAN AL
36303-6903
US

IV. Provider business mailing address

101 MEDICAL DR
DOTHAN AL
36303-6903
US

V. Phone/Fax

Practice location:
  • Phone: 334-702-7222
  • Fax: 334-702-1944
Mailing address:
  • Phone: 334-702-7222
  • Fax: 334-702-1944

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0804X
TaxonomyChild & Adolescent Psychiatry Physician
License Number25317
License Number StateAL

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name: JERLYN C. MCCLEOD
Title or Position: OWNER
Credential: M.D.
Phone: 334-702-7222