Provider Demographics
NPI:1477964732
Name:JUDD, JOHANNA MARIE (MS, OTR/L, CLT)
Entity Type:Individual
Prefix:MISS
First Name:JOHANNA
Middle Name:MARIE
Last Name:JUDD
Suffix:
Gender:F
Credentials:MS, OTR/L, CLT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:120 N CHURCHILL DR
Mailing Address - Street 2:
Mailing Address - City:ST AUGUSTINE
Mailing Address - State:FL
Mailing Address - Zip Code:32086-4171
Mailing Address - Country:US
Mailing Address - Phone:440-413-6379
Mailing Address - Fax:
Practice Address - Street 1:340 16TH AVE N STE B
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE BEACH
Practice Address - State:FL
Practice Address - Zip Code:32250-4819
Practice Address - Country:US
Practice Address - Phone:440-413-6379
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-05-08
Last Update Date:2019-09-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
225X00000X
FLOT16369225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist