Provider Demographics
NPI:1033811567
Name:JOHNSON, LIONEL JAY
Entity Type:Individual
Prefix:
First Name:LIONEL
Middle Name:JAY
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2821A LONGTOWN RD
Mailing Address - Street 2:
Mailing Address - City:SARAH
Mailing Address - State:MS
Mailing Address - Zip Code:38665-3837
Mailing Address - Country:US
Mailing Address - Phone:601-918-8047
Mailing Address - Fax:
Practice Address - Street 1:2821A LONGTOWN RD
Practice Address - Street 2:
Practice Address - City:SARAH
Practice Address - State:MS
Practice Address - Zip Code:38665-3837
Practice Address - Country:US
Practice Address - Phone:601-918-8047
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-03-20
Last Update Date:2023-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician