Healthcare Provider Details

I. General information

NPI: 1356729321
Provider Name (Legal Business Name): JOHNNY JEFFREY LAWRENCE
Entity Type: Individual
Gender: Male
Sole Proprietor: N

Provider Other Name: JOHN JEFFREY LAWRENCE JR.

II. Dates (important events)

Enumeration Date: 05/11/2015
Last Update Date: 12/30/2019
Certification Date: 12/30/2019
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3300 GALLOWS RD
FALLS CHURCH VA
22042-3307
US

IV. Provider business mailing address

550 S JACKSON ST
LOUISVILLE KY
40202-1622
US

V. Phone/Fax

Practice location:
  • Phone: 703-776-7113
  • Fax:
Mailing address:
  • Phone: 502-852-3751
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number0101268082
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: