Provider Demographics
NPI:1548906001
Name:JOHNSON, SALLIE D
Entity type:Individual
Prefix:
First Name:SALLIE
Middle Name:D
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 1:860 E RIVER PL
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:MS
Mailing Address - Zip Code:39202-3442
Mailing Address - Country:US
Mailing Address - Phone:769-252-5550
Mailing Address - Fax:
Practice Address - Street 1:822 WINN ST APT SUITE
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39204-5414
Practice Address - Country:US
Practice Address - Phone:601-832-7429
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-05-09
Last Update Date:2022-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health