Healthcare Provider Details

I. General information

NPI: 1982530564
Provider Name (Legal Business Name): JASMINE KIERA DIAMOND MAMIE JOHNSON MS, LCMHCA, LCASA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/22/2026
Last Update Date: 08/14/2026
Certification Date: 08/14/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4505 BUSHEL CT
AYDEN NC
28513-1507
US

IV. Provider business mailing address

4505 BUSHEL CT
AYDEN NC
28513-1507
US

V. Phone/Fax

Practice location:
  • Phone: 336-447-8211
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberA23002
License Number StateNC
# 2
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberLCAS-31719
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: