Provider Demographics
NPI:1467100586
Name:JOHNSON, JAQUENCIA D (LMT)
Entity Type:Individual
Prefix:
First Name:JAQUENCIA
Middle Name:D
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 1:7270 RUSTON DR
Mailing Address - Street 2:
Mailing Address - City:BAKER
Mailing Address - State:LA
Mailing Address - Zip Code:70714-5252
Mailing Address - Country:US
Mailing Address - Phone:225-573-9081
Mailing Address - Fax:225-349-8608
Practice Address - Street 1:5425 GALERIA DR STE F
Practice Address - Street 2:
Practice Address - City:BATON ROUGE
Practice Address - State:LA
Practice Address - Zip Code:70816-8004
Practice Address - Country:US
Practice Address - Phone:225-573-9081
Practice Address - Fax:225-349-8608
Is Sole Proprietor?:Yes
Enumeration Date:2022-03-17
Last Update Date:2022-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
171400000X
LA176B00000X
LALA8815225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist
No171400000XOther Service ProvidersHealth & Wellness Coach
No176B00000XOther Service ProvidersMidwife