Provider Demographics
NPI:1306366612
Name:JOHNSON, JENNIFER TRIMBLE (LICSW)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:TRIMBLE
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2514 QUAIL RIDGE LN SW
Mailing Address - Street 2:
Mailing Address - City:HUNTSVILLE
Mailing Address - State:AL
Mailing Address - Zip Code:35803-3534
Mailing Address - Country:US
Mailing Address - Phone:256-653-0904
Mailing Address - Fax:
Practice Address - Street 1:350 SUN TEMPLE DR
Practice Address - Street 2:
Practice Address - City:MADISON
Practice Address - State:AL
Practice Address - Zip Code:35758-5919
Practice Address - Country:US
Practice Address - Phone:256-325-2627
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-06-27
Last Update Date:2017-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL2192C-1074101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty