Provider Demographics
NPI:1427329812
Name:JOHNSON, KEISHAWN MARIE
Entity type:Individual
Prefix:MS
First Name:KEISHAWN
Middle Name:MARIE
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2626 CANAL ST STE 201
Mailing Address - Street 2:
Mailing Address - City:NEW ORLEANS
Mailing Address - State:LA
Mailing Address - Zip Code:70119-6410
Mailing Address - Country:US
Mailing Address - Phone:504-237-6979
Mailing Address - Fax:
Practice Address - Street 1:2626 CHARLES DR
Practice Address - Street 2:
Practice Address - City:CHALMETTE
Practice Address - State:LA
Practice Address - Zip Code:70043-3779
Practice Address - Country:US
Practice Address - Phone:504-237-6979
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-01-18
Last Update Date:2018-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
171M00000X
LA8373104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
No104100000XBehavioral Health & Social Service ProvidersSocial Worker