Provider Demographics
NPI:1609530583
Name:JOHNSON, TEMETRA JARAE
Entity Type:Individual
Prefix:
First Name:TEMETRA
Middle Name:JARAE
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 1:6862 MABLETON PKWY SE APT 203
Mailing Address - Street 2:
Mailing Address - City:MABLETON
Mailing Address - State:GA
Mailing Address - Zip Code:30126-6452
Mailing Address - Country:US
Mailing Address - Phone:619-771-7079
Mailing Address - Fax:
Practice Address - Street 1:5163 ROSWELL RD
Practice Address - Street 2:
Practice Address - City:SANDY SPRINGS
Practice Address - State:GA
Practice Address - Zip Code:30342-2206
Practice Address - Country:US
Practice Address - Phone:888-954-7959
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-10-26
Last Update Date:2021-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA21-189537106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician