Provider Demographics
NPI:1396084786
Name:SOUTHERN, JOHN STEPHEN (EDD)
Entity type:Individual
Prefix:DR
First Name:JOHN
Middle Name:STEPHEN
Last Name:SOUTHERN
Suffix:
Gender:M
Credentials:EDD
Other - Prefix:DR
Other - First Name:JOHN
Other - Middle Name:S
Other - Last Name:SOUTHERN
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:106 SUGALOCH CV
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:MS
Mailing Address - Zip Code:39211-3435
Mailing Address - Country:US
Mailing Address - Phone:618-762-0303
Mailing Address - Fax:
Practice Address - Street 1:106 SUGALOCH CV
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39211-3435
Practice Address - Country:US
Practice Address - Phone:618-762-0303
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-02-06
Last Update Date:2019-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL071009636103T00000X
MST0188106H00000X
MS0571101YP2500X
TX08559101YP2500X
PA003695103T00000X
CA30540103T00000X
IL071.009636103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No103T00000XBehavioral Health & Social Service ProvidersPsychologist
No106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL071.009636OtherCLINICAL PSYCHOLOGIST LICENSE
CA30540OtherPSYCHOLOGIST LICENSE
TX0571OtherPROFESSIONAL COUNSELOR LICENSE
MS0571OtherPROFESSIONAL COUNSELOR LICENSE
PAPS-003695-LOtherPSYCHOLOGIST LICENSE