Provider Demographics
NPI:1316548233
Name:JOHNSON, JHANE' HADIYA (LCAS)
Entity Type:Individual
Prefix:
First Name:JHANE'
Middle Name:HADIYA
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:LCAS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:200 GREAT RIDGE CT
Mailing Address - Street 2:
Mailing Address - City:MORRISVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:27560-6788
Mailing Address - Country:US
Mailing Address - Phone:919-218-4211
Mailing Address - Fax:
Practice Address - Street 1:1903 N HARRISON AVE STE 200
Practice Address - Street 2:
Practice Address - City:CARY
Practice Address - State:NC
Practice Address - Zip Code:27513-3093
Practice Address - Country:US
Practice Address - Phone:919-218-4211
Practice Address - Fax:877-292-0656
Is Sole Proprietor?:Yes
Enumeration Date:2020-11-06
Last Update Date:2020-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YA0400X
VA0906009697104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
NCLCAS26321OtherNC STATE LICENSE
VA0906009697OtherSUPERVISEE LICENSE
VA0734001439OtherTRAINEE MENTAL HEALTH PROFESSIONAL