Healthcare Provider Details

I. General information

NPI: 1972267581
Provider Name (Legal Business Name): JOSEPH JUSTIN MIXON
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/29/2021
Last Update Date: 10/29/2021
Certification Date: 10/29/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10414 JACKSON OAKS WAY STE 103
KNOXVILLE TN
37922-0704
US

IV. Provider business mailing address

1730 MAPLESTONE LN
KNOXVILLE TN
37918-1893
US

V. Phone/Fax

Practice location:
  • Phone: 865-888-6833
  • Fax:
Mailing address:
  • Phone: 865-719-3923
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number1923
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: