Provider Demographics
NPI:1609175298
Name:JOHNSON, TIFFANI JEANEE (MS OTR)
Entity Type:Individual
Prefix:MRS
First Name:TIFFANI
Middle Name:JEANEE
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:MS OTR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2535 LONE STAR DR
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75212-6313
Mailing Address - Country:US
Mailing Address - Phone:214-467-9787
Mailing Address - Fax:214-741-3665
Practice Address - Street 1:2535 LONE STAR DR
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75212-6313
Practice Address - Country:US
Practice Address - Phone:214-467-9787
Practice Address - Fax:214-741-3655
Is Sole Proprietor?:No
Enumeration Date:2011-03-22
Last Update Date:2014-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX114946172V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker