Provider Demographics
NPI:1164763959
Name:JOHNSON, JULIANNE DERISE (BA)
Entity Type:Individual
Prefix:
First Name:JULIANNE
Middle Name:DERISE
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:BA
Other - Prefix:MRS
Other - First Name:JULIANNE
Other - Middle Name:JOHNSON
Other - Last Name:LYLE
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:BA
Mailing Address - Street 1:2434 S EASON BLVD
Mailing Address - Street 2:
Mailing Address - City:TUPELO
Mailing Address - State:MS
Mailing Address - Zip Code:38804-6942
Mailing Address - Country:US
Mailing Address - Phone:662-842-9217
Mailing Address - Fax:662-680-6416
Practice Address - Street 1:2434 S EASON BLVD
Practice Address - Street 2:
Practice Address - City:TUPELO
Practice Address - State:MS
Practice Address - Zip Code:38804-6942
Practice Address - Country:US
Practice Address - Phone:662-842-9217
Practice Address - Fax:662-680-6416
Is Sole Proprietor?:No
Enumeration Date:2013-03-05
Last Update Date:2013-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor