Doctor Name: | JIMMY L MEDLOCK |
NPI Number: | 1194918458 |
Entity Type Code: | Individual (1) |
Gender: | M |
Credentials: | MSED |
License Number: | |
Business Practice Address: | 1109 Jones St Kennett, MO - 638573824 |
Business Phone Number: | 5738886545 |
Business Fax Number: | 5738882369 |
Mailing Address: | 1109 Jones St, KENNETT |
State: | MO |
Postal Code: | 638573824 |
Phone Number: | 5738886545 |
Fax Number: | 5738882369 |
NPI Enumeration Date: | 08/21/2007 |
NPI Last Update Date: | 08/21/2007 |
Replacement NPI: | 0 |
NPI Deactivation Date: | |
NPI Reactivation Date: |
Taxonomy Information: | |
Healthcare Provider Taxonomy: | 101YP2500X |
License Number: | |
Healthcare Provider Taxonomy: (Secondary) | Y |
State: | |
Taxonomy Type: | Behavioral Health & Social Service Providers |
Taxonomy Classification: | Counselor |
Taxonomy Specialization: | Professional |
Taxonomy Definition: |