Provider Demographics
NPI:1407211626
Name:JOHNSON, JACKY CATHERINE (LMFT)
Entity Type:Individual
Prefix:
First Name:JACKY
Middle Name:CATHERINE
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:LMFT
Other - Prefix:
Other - First Name:JACKY
Other - Middle Name:CATHERINE
Other - Last Name:HICKS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LMFT, LPC, CADC II
Mailing Address - Street 1:5262 N 148TH AVE
Mailing Address - Street 2:
Mailing Address - City:LITCHFIELD PARK
Mailing Address - State:AZ
Mailing Address - Zip Code:85340-2843
Mailing Address - Country:US
Mailing Address - Phone:503-484-5190
Mailing Address - Fax:623-322-1838
Practice Address - Street 1:5262 N 148TH AVE
Practice Address - Street 2:
Practice Address - City:LITCHFIELD PARK
Practice Address - State:AZ
Practice Address - Zip Code:85340-2843
Practice Address - Country:US
Practice Address - Phone:503-484-5190
Practice Address - Fax:623-322-1838
Is Sole Proprietor?:Yes
Enumeration Date:2015-12-16
Last Update Date:2021-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZLMFT-15214106H00000X
ORC2572101YP2500X
ORT0742106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional