Provider Demographics
NPI:1174189559
Name:JOHNSON, JACQUELINE (MS)
Entity Type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6711 GERMANTOWN AVE UNIT 18953
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19119-2181
Mailing Address - Country:US
Mailing Address - Phone:215-802-3533
Mailing Address - Fax:
Practice Address - Street 1:1550 LATIMER ST
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19102-4417
Practice Address - Country:US
Practice Address - Phone:215-802-3533
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-05-11
Last Update Date:2020-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health