Provider Demographics
NPI:1629282009
Name:JOHNSON, JONATHAN M (SOCIAL WORKER)
Entity Type:Individual
Prefix:
First Name:JONATHAN
Middle Name:M
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:SOCIAL WORKER
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2301 FOREST LANE
Mailing Address - Street 2:SUITE 400
Mailing Address - City:GARLAND
Mailing Address - State:TX
Mailing Address - Zip Code:75042
Mailing Address - Country:US
Mailing Address - Phone:972-272-1633
Mailing Address - Fax:972-487-0192
Practice Address - Street 1:2301 FOREST LANE
Practice Address - Street 2:SUITE 400
Practice Address - City:GARLAND
Practice Address - State:TX
Practice Address - Zip Code:75042
Practice Address - Country:US
Practice Address - Phone:972-272-1633
Practice Address - Fax:972-487-0192
Is Sole Proprietor?:No
Enumeration Date:2007-05-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX50715104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX50715OtherLICENSE NUMBER