Provider Demographics
NPI:1063676963
Name:JOHNSON, JANETTA WILSON
Entity Type:Individual
Prefix:MRS
First Name:JANETTA
Middle Name:WILSON
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:PO BOX 308
Mailing Address - Street 2:
Mailing Address - City:VICCO
Mailing Address - State:KY
Mailing Address - Zip Code:41773-0308
Mailing Address - Country:US
Mailing Address - Phone:606-642-4112
Mailing Address - Fax:
Practice Address - Street 1:114 ROUDY HOLLOW
Practice Address - Street 2:
Practice Address - City:SASSAFRAS
Practice Address - State:KY
Practice Address - Zip Code:41759-0308
Practice Address - Country:US
Practice Address - Phone:606-642-4112
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-07-10
Last Update Date:2008-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator