Provider Demographics
NPI:1205262730
Name:JOHNSON, JIMMIE LEE SR (COUNSELOR)
Entity type:Individual
Prefix:MR
First Name:JIMMIE
Middle Name:LEE
Last Name:JOHNSON
Suffix:SR
Gender:M
Credentials:COUNSELOR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:20724 EUREKA RD
Mailing Address - Street 2:
Mailing Address - City:TAYLOR
Mailing Address - State:MI
Mailing Address - Zip Code:48180
Mailing Address - Country:US
Mailing Address - Phone:734-759-0510
Mailing Address - Fax:734-324-3134
Practice Address - Street 1:20724 EUREKA RD
Practice Address - Street 2:
Practice Address - City:TAYLOR
Practice Address - State:MI
Practice Address - Zip Code:48180
Practice Address - Country:US
Practice Address - Phone:734-759-0510
Practice Address - Fax:734-324-3134
Is Sole Proprietor?:No
Enumeration Date:2013-09-16
Last Update Date:2013-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI2-00650101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor