Provider Demographics
NPI:1932624970
Name:JOHNSTON, JESSICA D (LLMSW)
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:D
Last Name:JOHNSTON
Suffix:
Gender:F
Credentials:LLMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11415 METTER AVE
Mailing Address - Street 2:
Mailing Address - City:WARREN
Mailing Address - State:MI
Mailing Address - Zip Code:48089-3841
Mailing Address - Country:US
Mailing Address - Phone:248-495-5764
Mailing Address - Fax:
Practice Address - Street 1:11415 METTER AVE
Practice Address - Street 2:
Practice Address - City:WARREN
Practice Address - State:MI
Practice Address - Zip Code:48089
Practice Address - Country:US
Practice Address - Phone:248-495-5764
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-08-10
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIM629083104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker