Provider Demographics
NPI:1225595259
Name:JOHNSON, JAMAAL DEON
Entity Type:Individual
Prefix:
First Name:JAMAAL
Middle Name:DEON
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 1:5450 WISSAHICKON AVE APT A624
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19144-5251
Mailing Address - Country:US
Mailing Address - Phone:202-550-8024
Mailing Address - Fax:
Practice Address - Street 1:390 REED RD FL 1
Practice Address - Street 2:
Practice Address - City:BROOMALL
Practice Address - State:PA
Practice Address - Zip Code:19008-4008
Practice Address - Country:US
Practice Address - Phone:484-450-6476
Practice Address - Fax:484-224-3398
Is Sole Proprietor?:Yes
Enumeration Date:2019-02-26
Last Update Date:2019-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PABH003968103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst