Provider Demographics
NPI:1740904176
Name:JOHNSON, MARQUETTA (LCSW)
Entity type:Individual
Prefix:
First Name:MARQUETTA
Middle Name:
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1910 MADISON AVE # 2153
Mailing Address - Street 2:
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38104-2620
Mailing Address - Country:US
Mailing Address - Phone:901-201-0308
Mailing Address - Fax:
Practice Address - Street 1:205 INGRAM BLVD
Practice Address - Street 2:
Practice Address - City:WEST MEMPHIS
Practice Address - State:AR
Practice Address - Zip Code:72301-3423
Practice Address - Country:US
Practice Address - Phone:870-739-6818
Practice Address - Fax:870-662-6826
Is Sole Proprietor?:Yes
Enumeration Date:2022-09-29
Last Update Date:2024-07-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR10492-C104100000X
TN92851041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical