Provider Demographics
NPI:1710998133
Name:JOHNSON, KATIE JEAN (MED)
Entity Type:Individual
Prefix:
First Name:KATIE
Middle Name:JEAN
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:MED
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1918 RANGER DR
Mailing Address - Street 2:
Mailing Address - City:GLENN HEIGHTS
Mailing Address - State:TX
Mailing Address - Zip Code:75154-8816
Mailing Address - Country:US
Mailing Address - Phone:469-235-3477
Mailing Address - Fax:469-519-3918
Practice Address - Street 1:1666 N HAMPTON RD
Practice Address - Street 2:SUITE 112
Practice Address - City:DESOTO
Practice Address - State:TX
Practice Address - Zip Code:75115-2390
Practice Address - Country:US
Practice Address - Phone:469-235-3477
Practice Address - Fax:469-519-3918
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-10
Last Update Date:2008-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX19793101YP2500X
AZ2561101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
7212LCOtherBCBS
TX7212LCOtherLICENSED PROF COUNSELOR
TX1790867Medicaid
7859920OtherAETNA