Provider Demographics
NPI:1316960107
Name:JOHNSON, JEFFREY ROBERT (LCSW-R)
Entity type:Individual
Prefix:MR
First Name:JEFFREY
Middle Name:ROBERT
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:LCSW-R
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:252 RANCH TRL W
Mailing Address - Street 2:
Mailing Address - City:WILLIAMSVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:14221-2246
Mailing Address - Country:US
Mailing Address - Phone:716-689-4326
Mailing Address - Fax:
Practice Address - Street 1:252 RANCH TRL W
Practice Address - Street 2:3495 BAILEY AVENUE
Practice Address - City:BUFFALO
Practice Address - State:NY
Practice Address - Zip Code:14221-2246
Practice Address - Country:US
Practice Address - Phone:716-834-4270
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYR0416101041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYR041610OtherLCSW-R