Provider Demographics
NPI:1639655095
Name:ROGERS, JOHNNY CHRISTOPHER
Entity Type:Individual
Prefix:
First Name:JOHNNY
Middle Name:CHRISTOPHER
Last Name:ROGERS
Suffix:
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 1:320 PAXTON LOOP
Mailing Address - Street 2:
Mailing Address - City:RED SPRINGS
Mailing Address - State:NC
Mailing Address - Zip Code:28377-9464
Mailing Address - Country:US
Mailing Address - Phone:910-843-4319
Mailing Address - Fax:
Practice Address - Street 1:30 DRAKES BRANCH DR
Practice Address - Street 2:
Practice Address - City:PEMBROKE
Practice Address - State:NC
Practice Address - Zip Code:28372-7325
Practice Address - Country:US
Practice Address - Phone:910-521-0092
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-07-18
Last Update Date:2018-12-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
P0122651041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical