Provider Demographics
NPI:1417621640
Name:JOHNSON, JACQUETTA (SOCIAL WORKER)
Entity Type:Individual
Prefix:MRS
First Name:JACQUETTA
Middle Name:
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:SOCIAL WORKER
Other - Prefix:
Other - First Name:JACQUETTA
Other - Middle Name:
Other - Last Name:BASS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:24463 W 10 MILE RD
Mailing Address - Street 2:
Mailing Address - City:SOUTHFIELD
Mailing Address - State:MI
Mailing Address - Zip Code:48033-2931
Mailing Address - Country:US
Mailing Address - Phone:248-302-2201
Mailing Address - Fax:
Practice Address - Street 1:24463 W 10 MILE RD
Practice Address - Street 2:
Practice Address - City:SOUTHFIELD
Practice Address - State:MI
Practice Address - Zip Code:48033-2931
Practice Address - Country:US
Practice Address - Phone:248-302-2201
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-08-02
Last Update Date:2021-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker