Healthcare Provider Details

I. General information

NPI: 1134202146
Provider Name (Legal Business Name): JEFF DAUGHERTY
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/23/2006
Last Update Date: 01/14/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

118 MAUPIN CIR
SHELBYVILLE TN
37160-3781
US

IV. Provider business mailing address

118 MAUPIN CIR
SHELBYVILLE TN
37160-3781
US

V. Phone/Fax

Practice location:
  • Phone: 931-680-7576
  • Fax: 931-536-4346
Mailing address:
  • Phone: 931-680-7576
  • Fax: 931-536-4346

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License NumberKY-163
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: