Healthcare Provider Details

I. General information

NPI: 1659651487
Provider Name (Legal Business Name): JESSE DAVID MALOTT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/24/2011
Last Update Date: 09/12/2026
Certification Date: 09/12/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2861 BROAD AVE
MEMPHIS TN
38112-2903
US

IV. Provider business mailing address

1020 S ARROYO PKWY
PASADENA CA
91105-3911
US

V. Phone/Fax

Practice location:
  • Phone: 901-701-2520
  • Fax: 901-325-6469
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number3381
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: