Provider Demographics
NPI:1003177577
Name:JOHNSON, JACQUELINE (LCSW)
Entity Type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:633 GIDNEY AVE
Mailing Address - Street 2:SUITE 6
Mailing Address - City:NEWBURGH
Mailing Address - State:NY
Mailing Address - Zip Code:12550-2800
Mailing Address - Country:US
Mailing Address - Phone:845-569-2900
Mailing Address - Fax:866-619-5710
Practice Address - Street 1:633 GIDNEY AVE
Practice Address - Street 2:SUITE 6
Practice Address - City:NEWBURGH
Practice Address - State:NY
Practice Address - Zip Code:12550-2800
Practice Address - Country:US
Practice Address - Phone:845-569-2900
Practice Address - Fax:866-619-5710
Is Sole Proprietor?:Yes
Enumeration Date:2012-05-31
Last Update Date:2012-05-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0784591041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical