Provider Demographics
NPI:1083070916
Name:JOHNSON, JAMIE
Entity Type:Individual
Prefix:
First Name:JAMIE
Middle Name:
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:JAMIE
Other - Middle Name:
Other - Last Name:JOHNSON
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:BA
Mailing Address - Street 1:PO BOX 78776
Mailing Address - Street 2:
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71137-8776
Mailing Address - Country:US
Mailing Address - Phone:318-675-0225
Mailing Address - Fax:318-675-0226
Practice Address - Street 1:1434 HAWN AVE STE 12
Practice Address - Street 2:
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71107-6508
Practice Address - Country:US
Practice Address - Phone:318-675-0225
Practice Address - Fax:318-675-0226
Is Sole Proprietor?:No
Enumeration Date:2016-01-07
Last Update Date:2016-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health