Provider Demographics
NPI:1356729321
Name:LAWRENCE, JOHNNY JEFFREY
Entity type:Individual
Prefix:
First Name:JOHNNY
Middle Name:JEFFREY
Last Name:LAWRENCE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:JOHN
Other - Middle Name:JEFFREY
Other - Last Name:LAWRENCE
Other - Suffix:JR
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:550 S JACKSON ST
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40202-1622
Mailing Address - Country:US
Mailing Address - Phone:502-852-3751
Mailing Address - Fax:
Practice Address - Street 1:3300 GALLOWS RD
Practice Address - Street 2:
Practice Address - City:FALLS CHURCH
Practice Address - State:VA
Practice Address - Zip Code:22042-3307
Practice Address - Country:US
Practice Address - Phone:703-776-7113
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-05-11
Last Update Date:2019-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
VA01012680822084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program