Provider Demographics
NPI:1407474109
Name:JOHNSON, JENA P (LCMHCA)
Entity Type:Individual
Prefix:
First Name:JENA
Middle Name:P
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:LCMHCA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6030 FORDING CREEK LN
Mailing Address - Street 2:
Mailing Address - City:KERNERSVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:27284-6347
Mailing Address - Country:US
Mailing Address - Phone:336-301-3426
Mailing Address - Fax:
Practice Address - Street 1:713 N EUGENE ST
Practice Address - Street 2:
Practice Address - City:GREENSBORO
Practice Address - State:NC
Practice Address - Zip Code:27401-1621
Practice Address - Country:US
Practice Address - Phone:336-270-9501
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-07-09
Last Update Date:2022-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCA15749101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health