Provider Demographics
NPI:1497435473
Name:JOHNSON, AMBRICA
Entity Type:Individual
Prefix:
First Name:AMBRICA
Middle Name:
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:AMBRICA
Other - Middle Name:
Other - Last Name:JACKSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:15 N STEWART ST
Mailing Address - Street 2:
Mailing Address - City:QUINCY
Mailing Address - State:FL
Mailing Address - Zip Code:32351-2335
Mailing Address - Country:US
Mailing Address - Phone:850-875-2180
Mailing Address - Fax:850-807-2970
Practice Address - Street 1:15 N STEWART ST
Practice Address - Street 2:
Practice Address - City:QUINCY
Practice Address - State:FL
Practice Address - Zip Code:32351-2335
Practice Address - Country:US
Practice Address - Phone:850-875-2180
Practice Address - Fax:850-807-2970
Is Sole Proprietor?:Yes
Enumeration Date:2023-07-24
Last Update Date:2023-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician