Provider Demographics
NPI:1720217417
Name:JOHNSON-WATTS, T. JEANETTE (LMSW)
Entity Type:Individual
Prefix:MS
First Name:T. JEANETTE
Middle Name:
Last Name:JOHNSON-WATTS
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:124 MALLARD ST
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29601-4046
Mailing Address - Country:US
Mailing Address - Phone:864-452-0557
Mailing Address - Fax:
Practice Address - Street 1:124 MALLARD ST
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:SC
Practice Address - Zip Code:29601-4046
Practice Address - Country:US
Practice Address - Phone:864-452-0557
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-07-02
Last Update Date:2013-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC9283104100000X
1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC1760596480Medicaid