Provider Demographics
NPI:1417768169
Name:DAVIS, JUSTIN (PMHNP)
Entity type:Individual
Prefix:
First Name:JUSTIN
Middle Name:
Last Name:DAVIS
Suffix:
Gender:
Credentials:PMHNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:529 PLEASANT HILL DR
Mailing Address - Street 2:
Mailing Address - City:COOKEVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:38501-2850
Mailing Address - Country:US
Mailing Address - Phone:931-267-8866
Mailing Address - Fax:
Practice Address - Street 1:1225 S WILLOW AVE STE 102
Practice Address - Street 2:
Practice Address - City:COOKEVILLE
Practice Address - State:TN
Practice Address - Zip Code:38506-4102
Practice Address - Country:US
Practice Address - Phone:931-284-4814
Practice Address - Fax:615-549-7044
Is Sole Proprietor?:No
Enumeration Date:2025-01-14
Last Update Date:2025-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN0000235209163W00000X
TN235209363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No163W00000XNursing Service ProvidersRegistered Nurse