Basic Information
| Provider Information | |||||||||
| NPI: | 1962139048 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | JOHNSON | ||||||||
| FirstName: | JAMES | ||||||||
| MiddleName: | GILMER | ||||||||
| NamePrefix: | MR. | ||||||||
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| Credential: | LCSW | ||||||||
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| Mailing Information | |||||||||
| Address1: | 440 OLD US 19 E | ||||||||
| Address2: | |||||||||
| City: | SPRUCE PINE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 287776106 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8287669966 | ||||||||
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| Practice Location | |||||||||
| Address1: | JAMES H QUILLEN VETERANS AFFAIRS MEDICAL CENTER | ||||||||
| Address2: | SYDNEY AND LAMONT STREET MOUNTAIN HOME, TN 37684 | ||||||||
| City: | MOUNTAIN HOME | ||||||||
| State: | TN | ||||||||
| PostalCode: | 37684 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4239261171 | ||||||||
| FaxNumber: | 4239792812 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/08/2022 | ||||||||
| LastUpdateDate: | 08/08/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 07/08/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | C007171 | NC | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
ID Information
| ID | Type | State | Issuer | Description | 007171 | 01 | NC | CLINICAL SOCIAL WORKER | OTHER |