Provider Demographics
NPI:1841414547
Name:JOHNSON, KEN FERRELL JR (PSYD)
Entity type:Individual
Prefix:DR
First Name:KEN
Middle Name:FERRELL
Last Name:JOHNSON
Suffix:JR
Gender:M
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:5422 1ST COAST HWY
Mailing Address - Street 2:STE 119
Mailing Address - City:AMELIA ISLAND
Mailing Address - State:FL
Mailing Address - Zip Code:32034-5423
Mailing Address - Country:US
Mailing Address - Phone:386-235-3831
Mailing Address - Fax:904-432-7088
Practice Address - Street 1:5422 1ST COAST HWY
Practice Address - Street 2:STE 119
Practice Address - City:AMELIA ISLAND
Practice Address - State:FL
Practice Address - Zip Code:32034-5423
Practice Address - Country:US
Practice Address - Phone:386-235-3831
Practice Address - Fax:904-432-7088
Is Sole Proprietor?:No
Enumeration Date:2007-04-12
Last Update Date:2015-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL5548101YM0800X, 101YA0400X, 103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No103T00000XBehavioral Health & Social Service ProvidersPsychologist