Provider Demographics
NPI:1932874005
Name:JOHNSON, KALAISHI
Entity Type:Individual
Prefix:
First Name:KALAISHI
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 1:4293 BERLIN DR
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:MS
Mailing Address - Zip Code:39211-6016
Mailing Address - Country:US
Mailing Address - Phone:601-672-5382
Mailing Address - Fax:
Practice Address - Street 1:604 HIGHWAY 80 W STE R
Practice Address - Street 2:
Practice Address - City:CLINTON
Practice Address - State:MS
Practice Address - Zip Code:39056-4108
Practice Address - Country:US
Practice Address - Phone:601-473-2106
Practice Address - Fax:601-473-2150
Is Sole Proprietor?:No
Enumeration Date:2021-08-11
Last Update Date:2023-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS3031101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional