Healthcare Provider Details

I. General information

NPI: 1972673556
Provider Name (Legal Business Name): JEFFREY LYNN JOHNSTON PH.D., LCSW, LPC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/09/2006
Last Update Date: 09/11/2025
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1221 N KINGSHIGHWAY ST IMPERIAL BUILDING
CAPE GIRARDEAU MO
63701-3506
US

IV. Provider business mailing address

PO BOX 645
CAPE GIRARDEAU MO
63702-0645
US

V. Phone/Fax

Practice location:
  • Phone: 573-335-7929
  • Fax: 573-335-6445
Mailing address:
  • Phone: 573-335-7929
  • Fax: 573-335-6445

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number001582
License Number StateMO
# 2
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number002119
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: