Healthcare Provider Details

I. General information

NPI: 1629402250
Provider Name (Legal Business Name): KESSHA JOHNSON ASW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/30/2013
Last Update Date: 06/30/2020
Certification Date: 06/30/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3117 WILSON RD
BAKERSFIELD CA
93304-5319
US

IV. Provider business mailing address

1430 TRUXTUN AVE STE 600
BAKERSFIELD CA
93301-5220
US

V. Phone/Fax

Practice location:
  • Phone: 661-324-4756
  • Fax:
Mailing address:
  • Phone: 661-635-3050
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberCATC III 133238
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number81832
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: