Healthcare Provider Details

I. General information

NPI: 1073054599
Provider Name (Legal Business Name): PRINCETTA JOHNSON
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/16/2017
Last Update Date: 03/16/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2715 MACKEY PL SUITE 135
SHREVEPORT LA
71118-2544
US

IV. Provider business mailing address

2715 MACKEY PL SUITE 135
SHREVEPORT LA
71118-2544
US

V. Phone/Fax

Practice location:
  • Phone: 318-220-8423
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: