Healthcare Provider Details

I. General information

NPI: 1104916766
Provider Name (Legal Business Name): JOHN CLEMMONS PHD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/13/2006
Last Update Date: 10/08/2020
Certification Date: 10/08/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

239 METHODIST BLVD
HATTIESBURG MS
39402-1297
US

IV. Provider business mailing address

239 METHODIST BLVD
HATTIESBURG MS
39402-1297
US

V. Phone/Fax

Practice location:
  • Phone: 601-296-2125
  • Fax: 601-268-8645
Mailing address:
  • Phone: 601-296-2125
  • Fax: 601-268-8645

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number52911
License Number StateMS
# 2
Primary TaxonomyN
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number52911
License Number StateMS
# 3
Primary TaxonomyN
Taxonomy Code103TC2200X
TaxonomyClinical Child & Adolescent Psychologist
License Number52911
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: