1407211626 NPI number — JACKY CATHERINE JOHNSON LMFT

Table of content: LISA A NAGLER MD (NPI 1093785644)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1407211626 NPI number — JACKY CATHERINE JOHNSON LMFT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
JOHNSON
Provider First Name:
JACKY
Provider Middle Name:
CATHERINE
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
LMFT
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
HICKS
Provider Other First Name:
JACKY
Provider Other Middle Name:
CATHERINE
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
LMFT, LPC, CADC II
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1407211626
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
01/21/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
5262 N 148TH AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LITCHFIELD PARK
Provider Business Mailing Address State Name:
AZ
Provider Business Mailing Address Postal Code:
85340-2843
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
503-484-5190
Provider Business Mailing Address Fax Number:
623-322-1838

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
5262 N 148TH AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LITCHFIELD PARK
Provider Business Practice Location Address State Name:
AZ
Provider Business Practice Location Address Postal Code:
85340-2843
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
503-484-5190
Provider Business Practice Location Address Fax Number:
623-322-1838
Provider Enumeration Date:
12/16/2015

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: 106H00000X , with the licence number:  LMFT-15214 , registered in the state of AZ ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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