Provider Demographics
NPI:1245545946
Name:JOHNSON, JACYE A (CSW)
Entity type:Individual
Prefix:
First Name:JACYE
Middle Name:A
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:CSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9882 VISTA CIR
Mailing Address - Street 2:
Mailing Address - City:UNION CITY
Mailing Address - State:GA
Mailing Address - Zip Code:30291-6022
Mailing Address - Country:US
Mailing Address - Phone:770-964-2024
Mailing Address - Fax:
Practice Address - Street 1:1200 LAKE HEARN DR NE
Practice Address - Street 2:SUITE 250
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30319-1415
Practice Address - Country:US
Practice Address - Phone:404-943-1070
Practice Address - Fax:404-943-0890
Is Sole Proprietor?:Yes
Enumeration Date:2010-08-18
Last Update Date:2010-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GACSW0032281041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA037384362OtherDRIVERS LICENSE