Provider Demographics
NPI:1578279584
Name:JOHNSON, JASMAINE
Entity Type:Individual
Prefix:
First Name:JASMAINE
Middle Name:
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:21576 IREDELL TER
Mailing Address - Street 2:
Mailing Address - City:BROADLANDS
Mailing Address - State:VA
Mailing Address - Zip Code:20148-5033
Mailing Address - Country:US
Mailing Address - Phone:510-738-7709
Mailing Address - Fax:844-333-0432
Practice Address - Street 1:21576 IREDELL TER
Practice Address - Street 2:
Practice Address - City:BROADLANDS
Practice Address - State:VA
Practice Address - Zip Code:20148-5033
Practice Address - Country:US
Practice Address - Phone:510-738-7709
Practice Address - Fax:844-333-0432
Is Sole Proprietor?:No
Enumeration Date:2023-01-24
Last Update Date:2023-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician