Provider Demographics
NPI:1578803763
Name:JOHNSON, KERRY CAMMILLA (PSYD, LPC, NCC)
Entity Type:Individual
Prefix:DR
First Name:KERRY
Middle Name:CAMMILLA
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:PSYD, LPC, NCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:500 E WOODROW WILSON AVE STE M
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:MS
Mailing Address - Zip Code:39216-4538
Mailing Address - Country:US
Mailing Address - Phone:417-849-8479
Mailing Address - Fax:
Practice Address - Street 1:500 E WOODROW WILSON AVE STE M
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39216-4538
Practice Address - Country:US
Practice Address - Phone:417-849-8479
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-02-25
Last Update Date:2015-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS1389101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional