Healthcare Provider Details

I. General information

NPI: 1508308008
Provider Name (Legal Business Name): TASHA JOHNSON
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/15/2016
Last Update Date: 07/03/2025
Certification Date: 07/03/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7 LAKELAND CIR
JACKSON MS
39216-5022
US

IV. Provider business mailing address

PO BOX 10551
JACKSON MS
39289-0551
US

V. Phone/Fax

Practice location:
  • Phone: 769-279-2474
  • Fax:
Mailing address:
  • Phone: 769-279-2474
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number127626
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: