Provider Demographics
NPI:1750565883
Name:JOHNSON, JENNIFER (MS, MS, MFA, LPC)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:MS, MS, MFA, LPC
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 1963
Mailing Address - Street 2:
Mailing Address - City:WILMINGTON
Mailing Address - State:NC
Mailing Address - Zip Code:28402-9997
Mailing Address - Country:US
Mailing Address - Phone:910-208-0518
Mailing Address - Fax:
Practice Address - Street 1:217 N 5TH AVE
Practice Address - Street 2:SUITE 103
Practice Address - City:WILMINGTON
Practice Address - State:NC
Practice Address - Zip Code:28401-4268
Practice Address - Country:US
Practice Address - Phone:910-208-0518
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-12-26
Last Update Date:2016-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC6478101YP2500X
GA2891101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional