Provider Demographics
NPI:1972673556
Name:JOHNSTON, JEFFREY LYNN (PHD, LCSW, LPC)
Entity Type:Individual
Prefix:DR
First Name:JEFFREY
Middle Name:LYNN
Last Name:JOHNSTON
Suffix:
Gender:M
Credentials:PHD, LCSW, LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 645
Mailing Address - Street 2:
Mailing Address - City:CAPE GIRARDEAU
Mailing Address - State:MO
Mailing Address - Zip Code:63702-0645
Mailing Address - Country:US
Mailing Address - Phone:573-335-7929
Mailing Address - Fax:573-335-6445
Practice Address - Street 1:1221 N KINGSHIGHWAY ST
Practice Address - Street 2:IMPERIAL BUILDING
Practice Address - City:CAPE GIRARDEAU
Practice Address - State:MO
Practice Address - Zip Code:63701-3506
Practice Address - Country:US
Practice Address - Phone:573-335-7929
Practice Address - Fax:573-335-6445
Is Sole Proprietor?:No
Enumeration Date:2006-11-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO001582101YP2500X
MO0021191041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Not Answered1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
2030308OtherCIGNA
111071OtherVALUE OPTIONS
19655OtherBLUE CROSS BLUE SHIELD
10852003OtherCAQH