Provider Demographics
NPI:1891045795
Name:JOHNSON, JACOB ALAN (LMFT)
Entity Type:Individual
Prefix:DR
First Name:JACOB
Middle Name:ALAN
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:219 MCKINLEY AVE
Mailing Address - Street 2:
Mailing Address - City:GENEVA
Mailing Address - State:IL
Mailing Address - Zip Code:60134
Mailing Address - Country:US
Mailing Address - Phone:773-892-2721
Mailing Address - Fax:
Practice Address - Street 1:2172 BLACKBERRY DR STE 205
Practice Address - Street 2:
Practice Address - City:GENEVA
Practice Address - State:IL
Practice Address - Zip Code:60134-1106
Practice Address - Country:US
Practice Address - Phone:630-492-1388
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-09-18
Last Update Date:2023-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL166.000941106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL208000274OtherASSOCIATES MARRIAGE & FAMILY THERAPY LICENSE