Healthcare Provider Details

I. General information

NPI: 1487553152
Provider Name (Legal Business Name): JAIE L JOHNSON LCMHC-A
Entity Type: Individual
Gender:
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/02/2026
Last Update Date: 11/02/2026
Certification Date: 11/01/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

120 BARBARY CT
CARY NC
27511-5861
US

IV. Provider business mailing address

120 BARBARY CT
CARY NC
27511-5861
US

V. Phone/Fax

Practice location:
  • Phone: 336-392-9308
  • Fax:
Mailing address:
  • Phone: 336-392-9308
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberA23408
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: