Provider Demographics
NPI:1508488396
Name:JOHNSON, JERMAINE MARCELL (MS, ABA, MBA)
Entity Type:Individual
Prefix:MR
First Name:JERMAINE
Middle Name:MARCELL
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:MS, ABA, MBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:765 LIMEKILN PIKE UNIT 7
Mailing Address - Street 2:
Mailing Address - City:GLENSIDE
Mailing Address - State:PA
Mailing Address - Zip Code:19038-3929
Mailing Address - Country:US
Mailing Address - Phone:215-962-4344
Mailing Address - Fax:
Practice Address - Street 1:1023 E BALTIMORE PIKE
Practice Address - Street 2:
Practice Address - City:MEDIA
Practice Address - State:PA
Practice Address - Zip Code:19063-5126
Practice Address - Country:US
Practice Address - Phone:610-449-1600
Practice Address - Fax:610-449-2655
Is Sole Proprietor?:Yes
Enumeration Date:2020-05-14
Last Update Date:2020-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PABH001435103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior AnalystGroup - Single Specialty