Provider Demographics
NPI:1639690381
Name:JOHNSON, JEFKIDA LASHA
Entity Type:Individual
Prefix:MS
First Name:JEFKIDA
Middle Name:LASHA
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 1:7007 POTSDAM CT
Mailing Address - Street 2:
Mailing Address - City:MONTGOMERY
Mailing Address - State:AL
Mailing Address - Zip Code:36117-8028
Mailing Address - Country:US
Mailing Address - Phone:334-320-0084
Mailing Address - Fax:888-856-7677
Practice Address - Street 1:320 1ST ST N STE 612
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE BEACH
Practice Address - State:FL
Practice Address - Zip Code:32250-6947
Practice Address - Country:US
Practice Address - Phone:334-647-1009
Practice Address - Fax:888-856-7677
Is Sole Proprietor?:No
Enumeration Date:2017-07-03
Last Update Date:2022-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL101YA0400X, 101YM0800X, 106H00000X
GA101YM0800X, 106H00000X
FL103TC1900X, 101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounseling
No106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL300011840Medicaid
FL840832Medicaid
AL241522Medicaid