Provider Demographics
NPI:1811160740
Name:JOHNSON, JACQUELINE
Entity type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:
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 1:2107 GARDENWOOD CT
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30349-3206
Mailing Address - Country:US
Mailing Address - Phone:404-857-8639
Mailing Address - Fax:404-863-1541
Practice Address - Street 1:2107 GARDENWOOD CT
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30349
Practice Address - Country:US
Practice Address - Phone:404-857-8639
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-04-11
Last Update Date:2019-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TH0100XBehavioral Health & Social Service ProvidersPsychologistHealth Service
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA372320984BMedicaid