Provider Demographics
NPI:1548277700
Name:JOHNSON, STEPHEN J (LCSW)
Entity type:Individual
Prefix:
First Name:STEPHEN
Middle Name:J
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1221 64TH CT
Mailing Address - Street 2:
Mailing Address - City:MERIDIAN
Mailing Address - State:MS
Mailing Address - Zip Code:39305-1124
Mailing Address - Country:US
Mailing Address - Phone:601-693-5633
Mailing Address - Fax:
Practice Address - Street 1:248 E CAPITOL ST
Practice Address - Street 2:840 TRUST MARK BLDG
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39201-2503
Practice Address - Country:US
Practice Address - Phone:800-632-6074
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-01
Last Update Date:2007-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSC0690101YM0800X, 1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MSP00364895OtherRR MCARE W PARADIGM
MSP00364895OtherRR MCARE W PARADIGM