Provider Demographics
NPI:1841874278
Name:THREADGILL-POWDERLL, JOHNETTA ELAINE
Entity type:Individual
Prefix:
First Name:JOHNETTA
Middle Name:ELAINE
Last Name:THREADGILL-POWDERLL
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:PO BOX 90864
Mailing Address - Street 2:
Mailing Address - City:SAN BERNARDINO
Mailing Address - State:CA
Mailing Address - Zip Code:92427-1864
Mailing Address - Country:US
Mailing Address - Phone:909-522-9069
Mailing Address - Fax:
Practice Address - Street 1:17057 FOOTHILL BLVD STE 205
Practice Address - Street 2:
Practice Address - City:FONTANA
Practice Address - State:CA
Practice Address - Zip Code:92335-3523
Practice Address - Country:US
Practice Address - Phone:909-693-3177
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-05-11
Last Update Date:2021-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAAPCC7643101YP2500X
CAAMFT118324106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional