Provider Demographics
NPI:1881434645
Name:JOHNSON, JENAE
Entity type:Individual
Prefix:
First Name:JENAE
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 1:1523 E LARNED ST APT 4
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48207-3031
Mailing Address - Country:US
Mailing Address - Phone:323-383-7325
Mailing Address - Fax:
Practice Address - Street 1:1523 E LARNED ST APT 4
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48207-3031
Practice Address - Country:US
Practice Address - Phone:323-383-7325
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-05-29
Last Update Date:2024-05-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6352001005103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical