Provider Demographics
NPI:1467025536
Name:JOHNSON, JAROD (LPC, LCDC)
Entity Type:Individual
Prefix:
First Name:JAROD
Middle Name:
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:LPC, LCDC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4701 PADRE BLVD UNIT 2076
Mailing Address - Street 2:
Mailing Address - City:SOUTH PADRE ISLAND
Mailing Address - State:TX
Mailing Address - Zip Code:78597-8051
Mailing Address - Country:US
Mailing Address - Phone:770-289-8209
Mailing Address - Fax:
Practice Address - Street 1:4405 PADRE BLVD
Practice Address - Street 2:
Practice Address - City:SOUTH PADRE ISLAND
Practice Address - State:TX
Practice Address - Zip Code:78597
Practice Address - Country:US
Practice Address - Phone:770-289-8209
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-07-19
Last Update Date:2021-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX14751101YA0400X
TX82350101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)