Healthcare Provider Details

I. General information

NPI: 1124249719
Provider Name (Legal Business Name): JOHN DAVID VICKERY PH.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/01/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3363 HIGHWAY 45 NORTH
JACKSON TN
38305
US

IV. Provider business mailing address

3363 HIGHWAY 45 NORTH
JACKSON TN
38305
US

V. Phone/Fax

Practice location:
  • Phone: 731-664-8444
  • Fax:
Mailing address:
  • Phone: 731-664-8444
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License NumberP1021
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: