Provider Demographics
NPI:1184060451
Name:JOHNSON, JEAN CAROL (LCDC)
Entity type:Individual
Prefix:MS
First Name:JEAN
Middle Name:CAROL
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:LCDC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:96 WHISPERING LAKE DR
Mailing Address - Street 2:
Mailing Address - City:SANTA ROSA BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32459-4286
Mailing Address - Country:US
Mailing Address - Phone:936-689-0914
Mailing Address - Fax:
Practice Address - Street 1:4408 DELWOOD LN
Practice Address - Street 2:
Practice Address - City:PANAMA CITY
Practice Address - State:FL
Practice Address - Zip Code:32408-7492
Practice Address - Country:US
Practice Address - Phone:850-636-7087
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-05-14
Last Update Date:2013-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX9929101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)