Healthcare Provider Details

I. General information

NPI: 1871745893
Provider Name (Legal Business Name): KIMBERLEE D JOHNSON LSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/22/2008
Last Update Date: 10/22/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3450 W 34TH AVE
PINE BLUFF AR
71603-5508
US

IV. Provider business mailing address

800 MARSHALL ST SLOT 900
LITTLE ROCK AR
72202-3510
US

V. Phone/Fax

Practice location:
  • Phone: 870-534-6067
  • Fax: 870-534-7392
Mailing address:
  • Phone: 501-364-3620
  • Fax: 501-364-3994

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number2837-B
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: