Provider Demographics
NPI:1700916012
Name:JOHNSON, JUDE EDWIN (LMFT)
Entity Type:Individual
Prefix:
First Name:JUDE
Middle Name:EDWIN
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:350 PEE DEE AVE
Mailing Address - Street 2:
Mailing Address - City:ALBEMARLE
Mailing Address - State:NC
Mailing Address - Zip Code:28001-4932
Mailing Address - Country:US
Mailing Address - Phone:704-986-1500
Mailing Address - Fax:800-227-8961
Practice Address - Street 1:5700 EXECUTIVE CENTER DR STE 110
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28212-8833
Practice Address - Country:US
Practice Address - Phone:704-525-3255
Practice Address - Fax:704-525-0949
Is Sole Proprietor?:No
Enumeration Date:2007-03-06
Last Update Date:2013-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC1166106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC1166OtherLMFT
NC6105168Medicaid