Provider Demographics
NPI:1205231628
Name:JOHNSON-BRISCOE, JELANI
Entity Type:Individual
Prefix:
First Name:JELANI
Middle Name:
Last Name:JOHNSON-BRISCOE
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 1:1239 HALSEY
Mailing Address - Street 2:
Mailing Address - City:VALLEJO
Mailing Address - State:CA
Mailing Address - Zip Code:94590
Mailing Address - Country:US
Mailing Address - Phone:925-917-0187
Mailing Address - Fax:
Practice Address - Street 1:300 ILENE ST.
Practice Address - Street 2:
Practice Address - City:MARTINEZ
Practice Address - State:CA
Practice Address - Zip Code:94553
Practice Address - Country:US
Practice Address - Phone:925-313-7980
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-10-28
Last Update Date:2014-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAF7427715OtherDRIVER'S LICENSE