Provider Demographics
NPI:1093578445
Name:JOHNSTON, NICHOLE ANN
Entity Type:Individual
Prefix:
First Name:NICHOLE
Middle Name:ANN
Last Name:JOHNSTON
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 1:138 EASTVIEW DR
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:OH
Mailing Address - Zip Code:45640-2048
Mailing Address - Country:US
Mailing Address - Phone:740-418-6277
Mailing Address - Fax:
Practice Address - Street 1:345 E MAIN ST STE C
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:OH
Practice Address - Zip Code:45640-1784
Practice Address - Country:US
Practice Address - Phone:740-577-3186
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-01-30
Last Update Date:2024-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH187178101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)