Provider Demographics
NPI:1972689065
Name:MACKINNON, JOHN ROSS (PHD)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:ROSS
Last Name:MACKINNON
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 1:567 VAUXHALL STREET EXT STE 323
Mailing Address - Street 2:
Mailing Address - City:WATERFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06385-4341
Mailing Address - Country:US
Mailing Address - Phone:860-447-9274
Mailing Address - Fax:860-447-9900
Practice Address - Street 1:567 VAUXHALL STREET EXT STE 323
Practice Address - Street 2:
Practice Address - City:WATERFORD
Practice Address - State:CT
Practice Address - Zip Code:06385-4341
Practice Address - Country:US
Practice Address - Phone:860-447-9274
Practice Address - Fax:860-447-9900
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-31
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT000771103TB0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TB0200XBehavioral Health & Social Service ProvidersPsychologistCognitive & Behavioral