Provider Demographics
NPI:1609433804
Name:JOHNSON, JACQUELINE COLLETTE (LMT, NTS)
Entity Type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:COLLETTE
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:LMT, NTS
Other - Prefix:
Other - First Name:JACQUELINE
Other - Middle Name:COLLETTE
Other - Last Name:PAYTIAMO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:612 MADEIRA DR SE
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87108-3614
Mailing Address - Country:US
Mailing Address - Phone:505-263-7882
Mailing Address - Fax:
Practice Address - Street 1:612 MADEIRA DR SE
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87108-3614
Practice Address - Country:US
Practice Address - Phone:505-263-7882
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-05-22
Last Update Date:2019-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM9685225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist