Provider Demographics
NPI:1629569165
Name:JOHNSON, JAMAAL CARLOS SR
Entity Type:Individual
Prefix:MR
First Name:JAMAAL
Middle Name:CARLOS
Last Name:JOHNSON
Suffix:SR
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:810 WILLOW BEND DR
Mailing Address - Street 2:
Mailing Address - City:JONESBORO
Mailing Address - State:GA
Mailing Address - Zip Code:30238-5956
Mailing Address - Country:US
Mailing Address - Phone:404-702-0961
Mailing Address - Fax:
Practice Address - Street 1:706 KING RD STE F
Practice Address - Street 2:
Practice Address - City:RIVERDALE
Practice Address - State:GA
Practice Address - Zip Code:30274-2034
Practice Address - Country:US
Practice Address - Phone:877-285-1780
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-05-21
Last Update Date:2018-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker