Provider Demographics
NPI:1245398163
Name:JOHNSTON, JANIS CLARK (EDD)
Entity Type:Individual
Prefix:DR
First Name:JANIS
Middle Name:CLARK
Last Name:JOHNSTON
Suffix:
Gender:F
Credentials:EDD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:424 IOWA ST
Mailing Address - Street 2:
Mailing Address - City:OAK PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60302-2230
Mailing Address - Country:US
Mailing Address - Phone:708-848-0250
Mailing Address - Fax:708-524-9126
Practice Address - Street 1:424 IOWA ST
Practice Address - Street 2:
Practice Address - City:OAK PARK
Practice Address - State:IL
Practice Address - Zip Code:60302-2230
Practice Address - Country:US
Practice Address - Phone:708-848-0250
Practice Address - Fax:708-524-9126
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-04
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL213075Medicare PIN