MEDICARE: DR. JOHN DAVID VICKERY PH.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	103T00000X	Psychologist	P1021	TN

General Provider Information

NPI Number	:	1124249719
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. JOHN DAVID VICKERY PH.D.

Provider Business Mailing Address
First Line	:	3363 HIGHWAY 45 NORTH
Second Line	:
City	:	JACKSON
State	:	TN
Zip	:	38305
Country	:	US
Telephone Number	:	731-664-8444
Fax Number	:

Provider Business Practice Location Address
First Line	:	3363 HIGHWAY 45 NORTH
Second Line	:
City	:	JACKSON
State	:	TN
Zip	:	38305
Country	:	US
Telephone Number	:	731-664-8444
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/01/2007
Last Update Date	:	07/08/2007

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