Provider Demographics
NPI:1235758087
Name:JOHNSON, KENDRA V (LCSW)
Entity Type:Individual
Prefix:MISS
First Name:KENDRA
Middle Name:V
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4150 ILLINOIS RD
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46804-1208
Mailing Address - Country:US
Mailing Address - Phone:866-710-7129
Mailing Address - Fax:800-886-7248
Practice Address - Street 1:3520 WASHINGTON BLVD
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46205-3719
Practice Address - Country:US
Practice Address - Phone:317-343-8355
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-04-12
Last Update Date:2020-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN34008781A1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical