Basic Information
| Provider Information | |||||||||
| NPI: | 1619493145 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | JOHNSON | ||||||||
| FirstName: | JEANETTE | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4019 GREENWOOD RD | ||||||||
| Address2: | |||||||||
| City: | SHREVEPORT | ||||||||
| State: | LA | ||||||||
| PostalCode: | 711096422 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3186265462 | ||||||||
| FaxNumber: | 3186265562 | ||||||||
| Practice Location | |||||||||
| Address1: | 4019 GREENWOOD ROAD | ||||||||
| Address2: | |||||||||
| City: | SHREVEPORT | ||||||||
| State: | LA | ||||||||
| PostalCode: | 71109 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3186265462 | ||||||||
| FaxNumber: | 3186265562 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/16/2017 | ||||||||
| LastUpdateDate: | 07/21/2022 | ||||||||
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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 | 101YM0800X | Y | Behavioral Health & Social Service Providers | Counselor | Mental Health |
No ID Information.