Healthcare Provider Details

I. General information

NPI: 1932379518
Provider Name (Legal Business Name): JACARRIAH JOHNSON
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/10/2008
Last Update Date: 02/09/2022
Certification Date: 02/09/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

161 W VICTORIA ST
LONG BEACH CA
90805-2175
US

IV. Provider business mailing address

19401 S VERMONT AVE STE A200
TORRANCE CA
90502-4418
US

V. Phone/Fax

Practice location:
  • Phone: 323-242-5000
  • Fax:
Mailing address:
  • Phone: 310-323-6887
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberC082899137
License Number StateOK
# 2
Primary TaxonomyN
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License NumberAMF87473
License Number StateCA
# 3
Primary TaxonomyN
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number87473
License Number StateCA
# 4
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number122173
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: