Provider Demographics
NPI:1487043071
Name:JOHNSON, JIMMY LORENZA SR
Entity Type:Individual
Prefix:
First Name:JIMMY
Middle Name:LORENZA
Last Name:JOHNSON
Suffix:SR
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 1:1080 MARINA VILLAGE PKWY
Mailing Address - Street 2:SUITE # 100
Mailing Address - City:ALAMEDA
Mailing Address - State:CA
Mailing Address - Zip Code:94501-6427
Mailing Address - Country:US
Mailing Address - Phone:510-337-7950
Mailing Address - Fax:510-337-7969
Practice Address - Street 1:1080 MARINA VILLAGE PKWY
Practice Address - Street 2:SUITE # 100
Practice Address - City:ALAMEDA
Practice Address - State:CA
Practice Address - Zip Code:94501-6427
Practice Address - Country:US
Practice Address - Phone:510-337-7950
Practice Address - Fax:510-337-7969
Is Sole Proprietor?:No
Enumeration Date:2015-01-20
Last Update Date:2015-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator