Provider Demographics
NPI:1568675981
Name:JOHNSON, JOEL JAIME JR (LPC)
Entity Type:Individual
Prefix:
First Name:JOEL
Middle Name:JAIME
Last Name:JOHNSON
Suffix:JR
Gender:M
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:200 MARRIOTT DRIVE
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:TX
Mailing Address - Zip Code:78374
Mailing Address - Country:US
Mailing Address - Phone:361-777-3991
Mailing Address - Fax:361-777-0610
Practice Address - Street 1:1165 E. MAIN
Practice Address - Street 2:
Practice Address - City:ALICE
Practice Address - State:TX
Practice Address - Zip Code:78332
Practice Address - Country:US
Practice Address - Phone:361-664-9587
Practice Address - Fax:361-777-0610
Is Sole Proprietor?:No
Enumeration Date:2007-05-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX16111101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX11315003Medicaid