Provider Demographics
NPI:1487810651
Name:JOHNSON, JILL GRACE (LCSW)
Entity type:Individual
Prefix:MS
First Name:JILL
Middle Name:GRACE
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:100 BREWSTER BLVD.
Mailing Address - Street 2:
Mailing Address - City:CAMP LEJEUNE - JACKSONVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28547
Mailing Address - Country:US
Mailing Address - Phone:910-450-4700
Mailing Address - Fax:910-450-4426
Practice Address - Street 1:100 BREWSTER BLVD.
Practice Address - Street 2:
Practice Address - City:CAMP LEJEUNE - JACKSONVILLE
Practice Address - State:NC
Practice Address - Zip Code:28547
Practice Address - Country:US
Practice Address - Phone:910-450-4700
Practice Address - Fax:910-450-4426
Is Sole Proprietor?:Yes
Enumeration Date:2008-08-06
Last Update Date:2025-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCC0061331041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC6106997Medicaid