Provider Demographics
NPI:1194398933
Name:JOHNSON, JASON PAUL (LIMITED PERMIT-LMHC)
Entity Type:Individual
Prefix:
First Name:JASON
Middle Name:PAUL
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:LIMITED PERMIT-LMHC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:241 ALEXANDER ST APT 101
Mailing Address - Street 2:
Mailing Address - City:ROCHESTER
Mailing Address - State:NY
Mailing Address - Zip Code:14607-2507
Mailing Address - Country:US
Mailing Address - Phone:301-821-3200
Mailing Address - Fax:
Practice Address - Street 1:21 WILLOW POND WAY STE 103
Practice Address - Street 2:
Practice Address - City:PENFIELD
Practice Address - State:NY
Practice Address - Zip Code:14526-2687
Practice Address - Country:US
Practice Address - Phone:585-385-6030
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-07-20
Last Update Date:2021-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYP110441101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health