Healthcare Provider Details

I. General information

NPI: 1760580583
Provider Name (Legal Business Name): JOEL I JOHNSON PH.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/20/2006
Last Update Date: 01/06/2025
Certification Date: 01/06/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6244 POPLAR
MEMPHIS TN
38119-4732
US

IV. Provider business mailing address

PO BOX 770211
MEMPHIS TN
38177-0211
US

V. Phone/Fax

Practice location:
  • Phone: 901-216-4354
  • Fax: 888-519-3386
Mailing address:
  • Phone: 901-216-4354
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License NumberP965
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: