Provider Demographics
NPI:1417336579
Name:JOHNSON, JESSICA M (PC,CDCA)
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:M
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:PC,CDCA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:204 COOK RD
Mailing Address - Street 2:SUITE 400
Mailing Address - City:LEBANON
Mailing Address - State:OH
Mailing Address - Zip Code:45036-9600
Mailing Address - Country:US
Mailing Address - Phone:513-228-7800
Mailing Address - Fax:513-695-2952
Practice Address - Street 1:975 KINGSVIEW DR
Practice Address - Street 2:BLDG A
Practice Address - City:LEBANON
Practice Address - State:OH
Practice Address - Zip Code:45036-9562
Practice Address - Country:US
Practice Address - Phone:513-228-7800
Practice Address - Fax:513-228-7845
Is Sole Proprietor?:No
Enumeration Date:2015-05-22
Last Update Date:2015-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHCDCA-150275-PRE101YA0400X
OHC-1400581101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)