Provider Demographics
NPI:1366003733
Name:JOHNSON, JERMAINE ANTONIO (RN)
Entity Type:Individual
Prefix:MR
First Name:JERMAINE
Middle Name:ANTONIO
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:433 FLOURNOY LUCAS RD LOT 52
Mailing Address - Street 2:
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71106-8115
Mailing Address - Country:US
Mailing Address - Phone:410-698-5064
Mailing Address - Fax:318-415-0300
Practice Address - Street 1:3341 YOUREE DR STE 205
Practice Address - Street 2:
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71105-2149
Practice Address - Country:US
Practice Address - Phone:318-219-4167
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-06-25
Last Update Date:2022-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA203158163WC1500X, 163WP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WP0808XNursing Service ProvidersRegistered NursePsychiatric/Mental Health
No163WC1500XNursing Service ProvidersRegistered NurseCommunity Health