Basic Information
| Provider Information | |||||||||
| NPI: | 1700916012 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | JOHNSON | ||||||||
| FirstName: | JUDE | ||||||||
| MiddleName: | EDWIN | ||||||||
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| Credential: | LMFT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 350 PEE DEE AVE | ||||||||
| Address2: | |||||||||
| City: | ALBEMARLE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 280014932 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7049861500 | ||||||||
| FaxNumber: | 8002278961 | ||||||||
| Practice Location | |||||||||
| Address1: | 5700 EXECUTIVE CENTER DR STE 110 | ||||||||
| Address2: | |||||||||
| City: | CHARLOTTE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 282128833 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7045253255 | ||||||||
| FaxNumber: | 7045250949 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/06/2007 | ||||||||
| LastUpdateDate: | 12/20/2013 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 106H00000X | 1166 | NC | Y | Behavioral Health & Social Service Providers | Marriage & Family Therapist |
ID Information
| ID | Type | State | Issuer | Description | 1166 | 01 | NC | LMFT | OTHER | 6105168 | 05 | NC | MEDICAID |