Provider Demographics
NPI:1932653755
Name:JOHNSON, TAMETRA LYNNETTE (LCSW)
Entity Type:Individual
Prefix:
First Name:TAMETRA
Middle Name:LYNNETTE
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2516 SAMARITAN DR STE D
Mailing Address - Street 2:
Mailing Address - City:SAN JOSE
Mailing Address - State:CA
Mailing Address - Zip Code:95124-4108
Mailing Address - Country:US
Mailing Address - Phone:408-471-4261
Mailing Address - Fax:
Practice Address - Street 1:2516 SAMARITAN DR STE D
Practice Address - Street 2:
Practice Address - City:SAN JOSE
Practice Address - State:CA
Practice Address - Zip Code:95124-4108
Practice Address - Country:US
Practice Address - Phone:408-471-4261
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-08-10
Last Update Date:2022-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA7439531041S0200X
CA693831041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No1041S0200XBehavioral Health & Social Service ProvidersSocial WorkerSchool