Basic Information
| Provider Information | |||||||||
| NPI: | 1487867032 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | JOHNSON | ||||||||
| FirstName: | CHASITY | ||||||||
| MiddleName: | L | ||||||||
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| Credential: | RD, LD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 23090 | ||||||||
| Address2: | MORGANTI - ADMIN FINANCE | ||||||||
| City: | JACKSON | ||||||||
| State: | MS | ||||||||
| PostalCode: | 392253090 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6019681362 | ||||||||
| FaxNumber: | 6012924592 | ||||||||
| Practice Location | |||||||||
| Address1: | 1225 NORTH STATE STREET | ||||||||
| Address2: | |||||||||
| City: | JACKSON | ||||||||
| State: | MS | ||||||||
| PostalCode: | 39202 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6019681362 | ||||||||
| FaxNumber: | 6012924592 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/08/2007 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 133V00000X | D0920 | MS | Y | Dietary & Nutritional Service Providers | Dietitian, Registered |
No ID Information.