Provider Demographics
NPI:1710679048
Name:JOHNSON, KENTREL (LAC)
Entity Type:Individual
Prefix:
First Name:KENTREL
Middle Name:
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:109 FRANKIE LN
Mailing Address - Street 2:
Mailing Address - City:WHITE HALL
Mailing Address - State:AR
Mailing Address - Zip Code:71602-2685
Mailing Address - Country:US
Mailing Address - Phone:870-247-3588
Mailing Address - Fax:870-247-2072
Practice Address - Street 1:109 FRANKIE LN
Practice Address - Street 2:
Practice Address - City:WHITE HALL
Practice Address - State:AR
Practice Address - Zip Code:71602-2685
Practice Address - Country:US
Practice Address - Phone:870-247-3588
Practice Address - Fax:870-247-2072
Is Sole Proprietor?:No
Enumeration Date:2023-05-24
Last Update Date:2023-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health