Provider Demographics
NPI:1093125916
Name:JOHNSON, JEFFREY WILLIAM
Entity Type:Individual
Prefix:MR
First Name:JEFFREY
Middle Name:WILLIAM
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:105 HIGH ST NE
Mailing Address - Street 2:
Mailing Address - City:WARREN
Mailing Address - State:OH
Mailing Address - Zip Code:44481-1219
Mailing Address - Country:US
Mailing Address - Phone:330-841-2316
Mailing Address - Fax:330-675-8620
Practice Address - Street 1:105 HIGH STREET
Practice Address - Street 2:
Practice Address - City:WARREN
Practice Address - State:OH
Practice Address - Zip Code:44483-5195
Practice Address - Country:US
Practice Address - Phone:330-814-2318
Practice Address - Fax:330-675-8620
Is Sole Proprietor?:No
Enumeration Date:2014-04-30
Last Update Date:2014-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHOH1242264103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool