Provider Demographics
NPI:1023580693
Name:MCLENDON, JOHN TYLER
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:TYLER
Last Name:MCLENDON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:128 ASBURY SQ
Mailing Address - Street 2:
Mailing Address - City:PEARL
Mailing Address - State:MS
Mailing Address - Zip Code:39208-9362
Mailing Address - Country:US
Mailing Address - Phone:601-946-0156
Mailing Address - Fax:
Practice Address - Street 1:1850 CHADWICK DR
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39204-3404
Practice Address - Country:US
Practice Address - Phone:601-376-1000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-12-20
Last Update Date:2018-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS122134367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered