Healthcare Provider Details

I. General information

NPI: 1194070946
Provider Name (Legal Business Name): JON R. WEBB PH.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/18/2012
Last Update Date: 07/18/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

807 UNIVERSITY PKWY 139 LUCILLE CLEMENT HALL
JOHNSON CITY TN
37614-6500
US

IV. Provider business mailing address

807 UNIVERSITY PKWY BOX 70649, ETSU
JOHNSON CITY TN
37614-6500
US

V. Phone/Fax

Practice location:
  • Phone: 423-439-7777
  • Fax: 423-439-7780
Mailing address:
  • Phone: 423-439-4466
  • Fax: 423-439-5695

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License NumberP2762
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: