Provider Demographics
NPI:1770943326
Name:JOHNSON, JENNIFER M
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:M
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17 FELTON PL
Mailing Address - Street 2:SUITE A
Mailing Address - City:CARTERSVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30120-2153
Mailing Address - Country:US
Mailing Address - Phone:770-386-8996
Mailing Address - Fax:
Practice Address - Street 1:17 FELTON PL
Practice Address - Street 2:SUITE A
Practice Address - City:CARTERSVILLE
Practice Address - State:GA
Practice Address - Zip Code:30120-2153
Practice Address - Country:US
Practice Address - Phone:770-386-8996
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-02-24
Last Update Date:2016-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPSY003974103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical