Provider Demographics
NPI:1245783760
Name:JOHNSON, JESSICA RAE (LPCC, NCC)
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:RAE
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:LPCC, NCC
Other - Prefix:MS
Other - First Name:JESSICA
Other - Middle Name:RAE
Other - Last Name:CHIVINGTON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:101 CYNTHIA LOOP NW
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87114-2414
Mailing Address - Country:US
Mailing Address - Phone:505-595-6622
Mailing Address - Fax:
Practice Address - Street 1:8214 2ND ST NW STE C
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87114-1091
Practice Address - Country:US
Practice Address - Phone:505-308-5226
Practice Address - Fax:505-514-0754
Is Sole Proprietor?:Yes
Enumeration Date:2016-08-02
Last Update Date:2021-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM0201921101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM63238730Medicaid