Provider Demographics
NPI:1184814634
Name:JOHNSTON, JENNIFER MARIE (LMHC, PHD)
Entity Type:Individual
Prefix:DR
First Name:JENNIFER
Middle Name:MARIE
Last Name:JOHNSTON
Suffix:
Gender:F
Credentials:LMHC, PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3 CONCORD AVE APT 43
Mailing Address - Street 2:
Mailing Address - City:CAMBRIDGE
Mailing Address - State:MA
Mailing Address - Zip Code:02138-3616
Mailing Address - Country:US
Mailing Address - Phone:617-803-6885
Mailing Address - Fax:
Practice Address - Street 1:1679 MASSACHUSETTS AVE
Practice Address - Street 2:SUITE 1
Practice Address - City:CAMBRIDGE
Practice Address - State:MA
Practice Address - Zip Code:02138-1807
Practice Address - Country:US
Practice Address - Phone:617-803-6885
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-07-31
Last Update Date:2019-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA9917103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA5306OtherALLIED MENTAL HEALTH LICE
MALM1021OtherBC/BS PROVIDER ID