Provider Demographics
NPI:1558813956
Name:JOHNSON, JAACQUELYN (BA SOCIOLOGY)
Entity Type:Individual
Prefix:
First Name:JAACQUELYN
Middle Name:
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:BA SOCIOLOGY
Other - Prefix:
Other - First Name:JACQUELYN
Other - Middle Name:RENEE
Other - Last Name:COATES
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:BA SOCIOLOGY
Mailing Address - Street 1:2207 IOELA ST
Mailing Address - Street 2:
Mailing Address - City:KILAUEA
Mailing Address - State:HI
Mailing Address - Zip Code:96754-5321
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2207 IOELA ST
Practice Address - Street 2:
Practice Address - City:KILAUEA
Practice Address - State:HI
Practice Address - Zip Code:96754-5321
Practice Address - Country:US
Practice Address - Phone:907-360-6614
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-11-01
Last Update Date:2016-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106E00000XBehavioral Health & Social Service ProvidersAssistant Behavior Analyst