Provider Demographics
NPI:1962718072
Name:JOHNSON, SAMANTHA LORENE (QBHP)
Entity type:Individual
Prefix:
First Name:SAMANTHA
Middle Name:LORENE
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:QBHP
Other - Prefix:
Other - First Name:SAMANTHA
Other - Middle Name:LORENE
Other - Last Name:YARBRO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1815 PLEASANT GROVE RD
Mailing Address - Street 2:
Mailing Address - City:JONESBORO
Mailing Address - State:AR
Mailing Address - Zip Code:72405-7870
Mailing Address - Country:US
Mailing Address - Phone:870-933-6886
Mailing Address - Fax:870-933-9395
Practice Address - Street 1:1815 PLEASANT GROVE RD
Practice Address - Street 2:
Practice Address - City:JONESBORO
Practice Address - State:AR
Practice Address - Zip Code:72405-7870
Practice Address - Country:US
Practice Address - Phone:870-933-6886
Practice Address - Fax:870-933-9395
Is Sole Proprietor?:No
Enumeration Date:2010-08-26
Last Update Date:2021-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
171M00000X, 174400000X
AR171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
No174400000XOther Service ProvidersSpecialist