Provider Demographics
NPI:1689938771
Name:JOHNSON, JEREMIAH (BS, MA, LCPC)
Entity Type:Individual
Prefix:
First Name:JEREMIAH
Middle Name:
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:BS, MA, LCPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:898 E 661 DIAG RD
Mailing Address - Street 2:
Mailing Address - City:LAWRENCE
Mailing Address - State:KS
Mailing Address - Zip Code:66047-9001
Mailing Address - Country:US
Mailing Address - Phone:785-542-9110
Mailing Address - Fax:
Practice Address - Street 1:1505 KASOLD DR STE 8
Practice Address - Street 2:
Practice Address - City:LAWRENCE
Practice Address - State:KS
Practice Address - Zip Code:66047-1601
Practice Address - Country:US
Practice Address - Phone:785-542-9110
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-07-03
Last Update Date:2022-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YM0800X, 171M00000X
KS03326101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No171M00000XOther Service ProvidersCase Manager/Care Coordinator