Provider Demographics
NPI:1225301757
Name:JOHNSON, JONATHAN
Entity Type:Individual
Prefix:
First Name:JONATHAN
Middle Name:
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 1:144 WATERSTON AVE
Mailing Address - Street 2:
Mailing Address - City:QUINCY
Mailing Address - State:MA
Mailing Address - Zip Code:02170-3432
Mailing Address - Country:US
Mailing Address - Phone:617-842-1205
Mailing Address - Fax:
Practice Address - Street 1:24 AIRPORT RD
Practice Address - Street 2:
Practice Address - City:WEST LEBANON
Practice Address - State:NH
Practice Address - Zip Code:03784-1663
Practice Address - Country:US
Practice Address - Phone:603-298-6617
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-02-14
Last Update Date:2020-03-03
Deactivation Date:2019-12-30
Deactivation Code:
Reactivation Date:2020-01-10
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health