Provider Demographics
NPI:1598386054
Name:JOHNSON, JASMINE PATRICE BRYANT
Entity Type:Individual
Prefix:
First Name:JASMINE
Middle Name:PATRICE BRYANT
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10130 MALLARD CREEK RD STE 300
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28262-6001
Mailing Address - Country:US
Mailing Address - Phone:704-469-7456
Mailing Address - Fax:704-946-6923
Practice Address - Street 1:10130 MALLARD CREEK RD STE 300
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28262-6001
Practice Address - Country:US
Practice Address - Phone:704-469-7456
Practice Address - Fax:704-946-6923
Is Sole Proprietor?:Yes
Enumeration Date:2020-05-06
Last Update Date:2023-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCA15736101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty