Healthcare Provider Details

I. General information

NPI: 1104726868
Provider Name (Legal Business Name): ANTOINETTE JOHNSON
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/06/2026
Last Update Date: 11/06/2026
Certification Date: 11/05/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

846 MONTICELLO ST
BROOKHAVEN MS
39601-2829
US

IV. Provider business mailing address

408 MAIN ST
BROOKHAVEN MS
39601-2829
US

V. Phone/Fax

Practice location:
  • Phone: 601-488-0383
  • Fax:
Mailing address:
  • Phone: 601-488-0383
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TH0100X
TaxonomyHealth Service Psychologist
License Number7192
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: