Provider Demographics
NPI:1104916766
Name:CLEMMONS, JOHN (PHD)
Entity type:Individual
Prefix:
First Name:JOHN
Middle Name:
Last Name:CLEMMONS
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:239 METHODIST BLVD
Mailing Address - Street 2:
Mailing Address - City:HATTIESBURG
Mailing Address - State:MS
Mailing Address - Zip Code:39402-1297
Mailing Address - Country:US
Mailing Address - Phone:601-296-2125
Mailing Address - Fax:601-268-8645
Practice Address - Street 1:239 METHODIST BLVD
Practice Address - Street 2:
Practice Address - City:HATTIESBURG
Practice Address - State:MS
Practice Address - Zip Code:39402-1297
Practice Address - Country:US
Practice Address - Phone:601-296-2125
Practice Address - Fax:601-268-8645
Is Sole Proprietor?:No
Enumeration Date:2006-10-13
Last Update Date:2020-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS52911103TC0700X, 103TC2200X, 103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
No103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & Adolescent
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS03051508Medicaid
MS256338YKD8Medicare PIN