Provider Demographics
NPI:1053902205
Name:JOHNSON, THEA VICTORIA JONES
Entity type:Individual
Prefix:
First Name:THEA
Middle Name:VICTORIA JONES
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2721 SADDLE DR
Mailing Address - Street 2:
Mailing Address - City:DURHAM
Mailing Address - State:NC
Mailing Address - Zip Code:27712-1823
Mailing Address - Country:US
Mailing Address - Phone:919-824-5520
Mailing Address - Fax:
Practice Address - Street 1:3711 UNIVERSITY DR STE C
Practice Address - Street 2:
Practice Address - City:DURHAM
Practice Address - State:NC
Practice Address - Zip Code:27707-6205
Practice Address - Country:US
Practice Address - Phone:919-405-2700
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-01-31
Last Update Date:2021-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCA16041101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health