Provider Demographics
NPI:1093589061
Name:FITZGERALD, CHAKATRIA JOHNSON (LMSW)
Entity Type:Individual
Prefix:MRS
First Name:CHAKATRIA
Middle Name:JOHNSON
Last Name:FITZGERALD
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5350 BRECKENWOOD DR
Mailing Address - Street 2:
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38127-2152
Mailing Address - Country:US
Mailing Address - Phone:318-719-0801
Mailing Address - Fax:601-962-7379
Practice Address - Street 1:5200 PARK AVE STE 202
Practice Address - Street 2:
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38119-3505
Practice Address - Country:US
Practice Address - Phone:901-676-2026
Practice Address - Fax:901-676-2027
Is Sole Proprietor?:No
Enumeration Date:2023-11-10
Last Update Date:2023-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN8622104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
TNQ038772Medicaid