1245783760 NPI number — JESSICA RAE JOHNSON LPCC, NCC

Table of content: JESSICA RAE JOHNSON LPCC, NCC (NPI 1245783760)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1245783760 NPI number — JESSICA RAE JOHNSON LPCC, NCC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
JOHNSON
Provider First Name:
JESSICA
Provider Middle Name:
RAE
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
LPCC, NCC
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
CHIVINGTON
Provider Other First Name:
JESSICA
Provider Other Middle Name:
RAE
Provider Other Name Prefix Text:
MS.
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1245783760
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
08/07/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
101 CYNTHIA LOOP NW
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ALBUQUERQUE
Provider Business Mailing Address State Name:
NM
Provider Business Mailing Address Postal Code:
87114-2414
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
505-595-6622
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
5701 CARMEL AVE NE STE B
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ALBUQUERQUE
Provider Business Practice Location Address State Name:
NM
Provider Business Practice Location Address Postal Code:
87113-2843
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
505-308-5226
Provider Business Practice Location Address Fax Number:
505-514-0754
Provider Enumeration Date:
08/02/2016

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 101YM0800X , with the licence number:  0201921 , registered in the state of NM ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 63238730 , issued by the state of ( NM ) . This identifiers is of the category "MEDICAID".




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