Provider Demographics
NPI:1134408636
Name:JOHNSON, LATISHA (LPC)
Entity type:Individual
Prefix:
First Name:LATISHA
Middle Name:
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:LATISHA
Other - Middle Name:
Other - Last Name:JACKSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 497
Mailing Address - Street 2:
Mailing Address - City:AUGUSTA
Mailing Address - State:AR
Mailing Address - Zip Code:72006-0497
Mailing Address - Country:US
Mailing Address - Phone:870-347-3475
Mailing Address - Fax:
Practice Address - Street 1:3150 E HERITAGE PKWY
Practice Address - Street 2:
Practice Address - City:FARMINGTON
Practice Address - State:AR
Practice Address - Zip Code:72730-5529
Practice Address - Country:US
Practice Address - Phone:479-400-1140
Practice Address - Fax:479-400-1151
Is Sole Proprietor?:No
Enumeration Date:2011-08-15
Last Update Date:2024-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARP1412110101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR116378726Medicaid