Provider Demographics
NPI:1457626178
Name:JOHNSON, JAMIE LYNN (LMT)
Entity Type:Individual
Prefix:
First Name:JAMIE
Middle Name:LYNN
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 583
Mailing Address - Street 2:
Mailing Address - City:MELROSE
Mailing Address - State:FL
Mailing Address - Zip Code:32666-0583
Mailing Address - Country:US
Mailing Address - Phone:352-475-1013
Mailing Address - Fax:
Practice Address - Street 1:5998 CENTRE ST
Practice Address - Street 2:SUITE E
Practice Address - City:MELROSE
Practice Address - State:FL
Practice Address - Zip Code:32666-6208
Practice Address - Country:US
Practice Address - Phone:352-475-1013
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-03-13
Last Update Date:2012-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMA42383225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLC2825OtherBLUE CROSS BLUE SHIELD OF FLORIDA