Provider Demographics
NPI:1013551035
Name:JOHNSON, JERILYN T (LCSW)
Entity Type:Individual
Prefix:
First Name:JERILYN
Middle Name:T
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 1:2452 W 500 S UNIT 7
Mailing Address - Street 2:
Mailing Address - City:SPRINGVILLE
Mailing Address - State:UT
Mailing Address - Zip Code:84663-5773
Mailing Address - Country:US
Mailing Address - Phone:801-557-3335
Mailing Address - Fax:
Practice Address - Street 1:2452 W 500 S UNIT 7
Practice Address - Street 2:
Practice Address - City:SPRINGVILLE
Practice Address - State:UT
Practice Address - Zip Code:84663-5773
Practice Address - Country:US
Practice Address - Phone:801-557-3335
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-11-01
Last Update Date:2019-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT7010989-35011041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty