Healthcare Provider Details

I. General information

NPI: 1255057154
Provider Name (Legal Business Name): JAMIE TEDDER PHD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/13/2022
Last Update Date: 10/13/2022
Certification Date: 10/12/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

809 LAMONT ST BLDG 162
JOHNSON CITY TN
37604-5453
US

IV. Provider business mailing address

809 LAMONT ST BLDG 162
JOHNSON CITY TN
37604-5453
US

V. Phone/Fax

Practice location:
  • Phone: 423-926-1171
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number0810007969
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: