Provider Demographics
NPI:1174862254
Name:JOHNSON, JACQUELYN
Entity Type:Individual
Prefix:
First Name:JACQUELYN
Middle Name:
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 1:6800 CENTRAL HILLS CT
Mailing Address - Street 2:
Mailing Address - City:LANDOVER
Mailing Address - State:MD
Mailing Address - Zip Code:20785-4371
Mailing Address - Country:US
Mailing Address - Phone:301-326-6387
Mailing Address - Fax:
Practice Address - Street 1:6800 CENTRAL HILLS CT
Practice Address - Street 2:
Practice Address - City:LANDOVER
Practice Address - State:MD
Practice Address - Zip Code:20785-4371
Practice Address - Country:US
Practice Address - Phone:301-326-6387
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-02-08
Last Update Date:2024-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDAC1766101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)