Provider Demographics
NPI:1275016149
Name:JOHNSON, STEPHEN DWAYNE
Entity Type:Individual
Prefix:
First Name:STEPHEN
Middle Name:DWAYNE
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 1:2987 CAPTIVA BLUFF RD N
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32226-2063
Mailing Address - Country:US
Mailing Address - Phone:904-803-4530
Mailing Address - Fax:
Practice Address - Street 1:2392 EDGEWOOD AVE N
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32254-1725
Practice Address - Country:US
Practice Address - Phone:904-781-7797
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-09-07
Last Update Date:2018-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker