Provider Demographics
NPI:1588975320
Name:JOHNSON, JACQUELYNN S (MSW)
Entity type:Individual
Prefix:
First Name:JACQUELYNN
Middle Name:S
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:MSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10635 OCEAN BEACH RD
Mailing Address - Street 2:
Mailing Address - City:CLARKLAKE
Mailing Address - State:MI
Mailing Address - Zip Code:49234-9010
Mailing Address - Country:US
Mailing Address - Phone:517-529-4928
Mailing Address - Fax:
Practice Address - Street 1:10635 OCEAN BEACH RD
Practice Address - Street 2:
Practice Address - City:CLARKLAKE
Practice Address - State:MI
Practice Address - Zip Code:49234-9010
Practice Address - Country:US
Practice Address - Phone:517-416-9186
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-06-26
Last Update Date:2010-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6801057927104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI6801057927OtherMASTER'S SOCIAL WORKER CLINICAL AND MACRO LICENSE