Provider Demographics
NPI:1184071185
Name:JOHNSON, JENNIFER (MA, LMHCA)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:MA, LMHCA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1126 NE PARK DR
Mailing Address - Street 2:
Mailing Address - City:ISSAQUAH
Mailing Address - State:WA
Mailing Address - Zip Code:98029-7410
Mailing Address - Country:US
Mailing Address - Phone:425-996-8288
Mailing Address - Fax:
Practice Address - Street 1:1126 NE PARK DR
Practice Address - Street 2:
Practice Address - City:ISSAQUAH
Practice Address - State:WA
Practice Address - Zip Code:98029-7410
Practice Address - Country:US
Practice Address - Phone:425-996-8288
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-05-19
Last Update Date:2016-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMC60625165101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health