Provider Demographics
NPI:1235644873
Name:JOHNSON, ASHLEY NICOLE CLAY
Entity Type:Individual
Prefix:
First Name:ASHLEY
Middle Name:NICOLE CLAY
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1200 MONROE ST
Mailing Address - Street 2:
Mailing Address - City:GRETNA
Mailing Address - State:LA
Mailing Address - Zip Code:70053-2307
Mailing Address - Country:US
Mailing Address - Phone:504-309-6798
Mailing Address - Fax:
Practice Address - Street 1:2519 HUEY P LONG AVE
Practice Address - Street 2:
Practice Address - City:GRETNA
Practice Address - State:LA
Practice Address - Zip Code:70053-6919
Practice Address - Country:US
Practice Address - Phone:504-975-8011
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-12-05
Last Update Date:2023-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1063728491Medicaid