Provider Demographics
NPI:1508186156
Name:JOHNSON, LAKREESE (PAC)
Entity Type:Individual
Prefix:
First Name:LAKREESE
Middle Name:
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:PAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3855 COOPER ST
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:MI
Mailing Address - Zip Code:49201-7547
Mailing Address - Country:US
Mailing Address - Phone:517-780-5991
Mailing Address - Fax:
Practice Address - Street 1:3855 COOPER ST
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:MI
Practice Address - Zip Code:49201-7547
Practice Address - Country:US
Practice Address - Phone:517-780-5991
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-06-06
Last Update Date:2017-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI56010056792084P0800X, 363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry