Provider Demographics
NPI:1003946526
Name:JOHNSON, JEFFERY J (LPCC)
Entity Type:Individual
Prefix:
First Name:JEFFERY
Middle Name:J
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:LPCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:707 BROADWAY BLVD NE
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87102-2360
Mailing Address - Country:US
Mailing Address - Phone:505-382-9169
Mailing Address - Fax:505-342-5414
Practice Address - Street 1:707 BROADWAY BLVD NE
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87102-2360
Practice Address - Country:US
Practice Address - Phone:505-382-9169
Practice Address - Fax:505-342-5414
Is Sole Proprietor?:No
Enumeration Date:2007-03-06
Last Update Date:2021-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMCCMH0216531101YP2500X
CO2576101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO35773561Medicaid