Provider Demographics
NPI:1144575382
Name:BUCK, JOHNNY JASON (LPC)
Entity Type:Individual
Prefix:DR
First Name:JOHNNY
Middle Name:JASON
Last Name:BUCK
Suffix:
Gender:M
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14256 S 47TH ST
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85044-6205
Mailing Address - Country:US
Mailing Address - Phone:480-510-8502
Mailing Address - Fax:
Practice Address - Street 1:14256 S 47TH ST
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85044-6205
Practice Address - Country:US
Practice Address - Phone:480-510-8502
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-07-13
Last Update Date:2012-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZLPC-13746101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional