Provider Demographics
NPI:1407562408
Name:JOHNSON, PHILLIP D'JUAN
Entity Type:Individual
Prefix:
First Name:PHILLIP
Middle Name:D'JUAN
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 1:882 OAKMAN BLVD
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48238-3710
Mailing Address - Country:US
Mailing Address - Phone:313-967-5950
Mailing Address - Fax:
Practice Address - Street 1:882 OAKMAN BLVD
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48238-3710
Practice Address - Country:US
Practice Address - Phone:313-967-5950
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-01-24
Last Update Date:2023-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker