Provider Demographics
NPI:1609810092
Name:SKINNER, JOHN ROBERT JR (PHD)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:ROBERT
Last Name:SKINNER
Suffix:JR
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 1:307 SHOREWOOD DR
Mailing Address - Street 2:
Mailing Address - City:DUNCANVILLE
Mailing Address - State:TX
Mailing Address - Zip Code:75116-3632
Mailing Address - Country:US
Mailing Address - Phone:972-298-8701
Mailing Address - Fax:972-709-5786
Practice Address - Street 1:508 GRACE ST
Practice Address - Street 2:
Practice Address - City:WAXAHACHIE
Practice Address - State:TX
Practice Address - Zip Code:75165-3046
Practice Address - Country:US
Practice Address - Phone:714-536-2570
Practice Address - Fax:972-709-5786
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-15
Last Update Date:2010-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX2-3650103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX133709903Medicaid
TX133709905Medicaid
TX133709902Medicaid
TX86087AOtherBLUE CROSS BLUE SHIELD
TX82292PMedicare ID - Type Unspecified
TX133709905Medicaid
TX133709903Medicaid