Healthcare Provider Details

I. General information

NPI: 1407025216
Provider Name (Legal Business Name): JANINE MARIE JOHNSTON LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: JANINE MARIE WANKE LCSW

II. Dates (important events)

Enumeration Date: 02/26/2008
Last Update Date: 02/27/2023
Certification Date: 02/27/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

101 KIDSPEACE DR
BOWDON GA
30108-3447
US

IV. Provider business mailing address

153 PAYNES LAKE RD
CARROLLTON GA
30116-5732
US

V. Phone/Fax

Practice location:
  • Phone: 770-437-7200
  • Fax: 770-258-9128
Mailing address:
  • Phone: 404-683-4831
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberCSW003840
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: