Provider Demographics
NPI:1073054599
Name:JOHNSON, PRINCETTA
Entity Type:Individual
Prefix:
First Name:PRINCETTA
Middle Name:
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2715 MACKEY PL
Mailing Address - Street 2:SUITE 135
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71118-2544
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2715 MACKEY PL
Practice Address - Street 2:SUITE 135
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71118-2544
Practice Address - Country:US
Practice Address - Phone:318-220-8423
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-03-16
Last Update Date:2017-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health