Provider Demographics
NPI:1730653551
Name:JOHNSON, DEDERICKA (MS)
Entity Type:Individual
Prefix:
First Name:DEDERICKA
Middle Name:
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2347 ROSSVILLE BLVD
Mailing Address - Street 2:
Mailing Address - City:CHATTANOOGA
Mailing Address - State:TN
Mailing Address - Zip Code:37408-2250
Mailing Address - Country:US
Mailing Address - Phone:423-320-2431
Mailing Address - Fax:
Practice Address - Street 1:2347 ROSSVILLE BLVD
Practice Address - Street 2:
Practice Address - City:CHATTANOOGA
Practice Address - State:TN
Practice Address - Zip Code:37408-2250
Practice Address - Country:US
Practice Address - Phone:423-320-2431
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-01-15
Last Update Date:2019-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)