Provider Demographics
NPI:1487144952
Name:JOHNSON, KENNETH CORNELL JR (CDCA)
Entity type:Individual
Prefix:MR
First Name:KENNETH
Middle Name:CORNELL
Last Name:JOHNSON
Suffix:JR
Gender:M
Credentials:CDCA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:232 WIMBLEDON DR
Mailing Address - Street 2:
Mailing Address - City:MANSFIELD
Mailing Address - State:OH
Mailing Address - Zip Code:44906-2451
Mailing Address - Country:US
Mailing Address - Phone:419-571-2188
Mailing Address - Fax:
Practice Address - Street 1:91 PARK AVE W
Practice Address - Street 2:
Practice Address - City:MANSFIELD
Practice Address - State:OH
Practice Address - Zip Code:44902-1630
Practice Address - Country:US
Practice Address - Phone:567-307-7269
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-05-10
Last Update Date:2018-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH040353101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)