Healthcare Provider Details

I. General information

NPI: 1124983259
Provider Name (Legal Business Name): JENNIFER JOHNSON
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/20/2025
Last Update Date: 12/20/2025
Certification Date: 12/20/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

722 RIDGE BROOK TRL
DULUTH GA
30096-6806
US

IV. Provider business mailing address

722 RIDGE BROOK TRL
DULUTH GA
30096-6806
US

V. Phone/Fax

Practice location:
  • Phone: 678-613-1436
  • Fax:
Mailing address:
  • Phone: 678-613-1436
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: