Provider Demographics
NPI:1467406728
Name:JOHNSON, GEORGETTE (PSYD)
Entity Type:Individual
Prefix:
First Name:GEORGETTE
Middle Name:
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2700 WEDGEWOOD DR
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:MO
Mailing Address - Zip Code:63755-3251
Mailing Address - Country:US
Mailing Address - Phone:573-334-7471
Mailing Address - Fax:
Practice Address - Street 1:619 N BROADVIEW ST
Practice Address - Street 2:
Practice Address - City:CAPE GIRARDEAU
Practice Address - State:MO
Practice Address - Zip Code:63701-4313
Practice Address - Country:US
Practice Address - Phone:573-334-3486
Practice Address - Fax:573-334-3524
Is Sole Proprietor?:No
Enumeration Date:2006-05-20
Last Update Date:2008-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO1999140485103TC2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & Adolescent
Provider Identifiers
StateIdentifier IDID TypeIssuer
146377OtherBLUE CROSS BLUE SHIELD
430142OtherCENTURY PLANNERS
430142OtherFORTIS/HL
430142OtherHEALTHLINK
431823864OtherMAGELLAN
430142OtherHEALTHLINK FREEDOM
431823864OtherMULTIPLAN
MO493874812Medicaid
43042OtherEPOCH
MO431823864OtherCORPHEALTH
431823864OtherGREATWEST
431823864OtherMISSOURI ALLIANCE
5633811OtherFIRSTHEALTH
430142OtherFORTIS/HL
431823864OtherGREATWEST
MO493874812Medicaid