Provider Demographics
NPI:1265088470
Name:JOHNSON, JENETTA (LLMSW-CLINICAL)
Entity type:Individual
Prefix:
First Name:JENETTA
Middle Name:
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:LLMSW-CLINICAL
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:201 N SQUIRREL RD APT 911
Mailing Address - Street 2:
Mailing Address - City:AUBURN HILLS
Mailing Address - State:MI
Mailing Address - Zip Code:48326-4024
Mailing Address - Country:US
Mailing Address - Phone:248-935-6083
Mailing Address - Fax:
Practice Address - Street 1:1685 BALDWIN AVE STE 100
Practice Address - Street 2:
Practice Address - City:PONTIAC
Practice Address - State:MI
Practice Address - Zip Code:48340-1242
Practice Address - Country:US
Practice Address - Phone:248-706-3450
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-08-13
Last Update Date:2019-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6801104814104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker