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NPI Code Detail

MEDICARE: JACEY COLE JOHNSON LCSW

MEDICARE: JACEY COLE JOHNSON LCSW
Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

# Taxonomy Code Taxonomy License Number License Number State
11041C0700XClinical Social WorkerC010714NC

General Provider Information

NPI Number : 1114322583
Entity Type Code : Individual
Provider Name (Legal Business Name) : JACEY COLE JOHNSON LCSW
Provider Business Mailing Address
First Line : 150 S NEVADA HIGHWAY 160 STE 8-575
Second Line :
City : PAHRUMP
State : NV
Zip : 89048-2176
Country : US
Telephone Number :
Fax Number :
Provider Business Practice Location Address
First Line : 4700 LAS VEGAS BLVD N
Second Line :
City : NELLIS AFB
State : NV
Zip : 89191-6600
Country : US
Telephone Number : 702-653-2273
Fax Number :
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 10/28/2014
Last Update Date : 03/19/2026

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