Provider Demographics
NPI:1164625240
Name:JOHNSON, JAKE A (DOCTORATE)
Entity Type:Individual
Prefix:DR
First Name:JAKE
Middle Name:A
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:DOCTORATE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6111 BEDDINGFIELD CT
Mailing Address - Street 2:
Mailing Address - City:CENTREVILLE
Mailing Address - State:VA
Mailing Address - Zip Code:20121-5318
Mailing Address - Country:US
Mailing Address - Phone:703-502-1029
Mailing Address - Fax:301-262-7637
Practice Address - Street 1:14300 GALLANT FOX LN
Practice Address - Street 2:SUITE 211
Practice Address - City:BOWIE
Practice Address - State:MD
Practice Address - Zip Code:20715-4003
Practice Address - Country:US
Practice Address - Phone:301-262-2828
Practice Address - Fax:301-262-7637
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD297101YM0800X, 101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Not Answered101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional