Provider Demographics
NPI:1396273850
Name:JOHNSON, JEROD (MS)
Entity type:Individual
Prefix:
First Name:JEROD
Middle Name:
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 23070
Mailing Address - Street 2:
Mailing Address - City:BARLING
Mailing Address - State:AR
Mailing Address - Zip Code:72923-0070
Mailing Address - Country:US
Mailing Address - Phone:479-452-5040
Mailing Address - Fax:479-452-5047
Practice Address - Street 1:949 N MAIN ST
Practice Address - Street 2:
Practice Address - City:MULBERRY
Practice Address - State:AR
Practice Address - Zip Code:72947-8538
Practice Address - Country:US
Practice Address - Phone:479-452-5040
Practice Address - Fax:479-452-5047
Is Sole Proprietor?:Yes
Enumeration Date:2017-05-30
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARA1707231101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health