Provider Demographics
NPI:1598299877
Name:JOHNSON, WILSON ERIC JR (MACM)
Entity Type:Individual
Prefix:
First Name:WILSON
Middle Name:ERIC
Last Name:JOHNSON
Suffix:JR
Gender:M
Credentials:MACM
Other - Prefix:MR
Other - First Name:WILSON
Other - Middle Name:ERIC
Other - Last Name:JOHNSON
Other - Suffix:JR
Other - Last Name Type:Professional Name
Other - Credentials:MACM
Mailing Address - Street 1:3038 YORKTOWN DR
Mailing Address - Street 2:
Mailing Address - City:BATON ROUGE
Mailing Address - State:LA
Mailing Address - Zip Code:70808-3471
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3038 YORKTOWN DR
Practice Address - Street 2:
Practice Address - City:BATON ROUGE
Practice Address - State:LA
Practice Address - Zip Code:70808-3471
Practice Address - Country:US
Practice Address - Phone:225-572-2908
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-04-13
Last Update Date:2017-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor