Provider Demographics
NPI:1497124937
Name:JOHNSON, JASHAUN
Entity Type:Individual
Prefix:
First Name:JASHAUN
Middle Name:
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 1:111 BISHOP CT
Mailing Address - Street 2:
Mailing Address - City:NOVATO
Mailing Address - State:CA
Mailing Address - Zip Code:94945-3401
Mailing Address - Country:US
Mailing Address - Phone:707-853-8829
Mailing Address - Fax:415-492-0834
Practice Address - Street 1:111 BISHOP CT
Practice Address - Street 2:
Practice Address - City:NOVATO
Practice Address - State:CA
Practice Address - Zip Code:94945-3401
Practice Address - Country:US
Practice Address - Phone:707-853-8829
Practice Address - Fax:415-492-0834
Is Sole Proprietor?:Yes
Enumeration Date:2015-09-15
Last Update Date:2015-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAR111241214101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAB6844483Medicaid