Provider Demographics
NPI:1659658953
Name:JOHNSON, ESSENCE
Entity Type:Individual
Prefix:
First Name:ESSENCE
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 1:4825 NE 48TH ST
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73121-6233
Mailing Address - Country:US
Mailing Address - Phone:405-593-3008
Mailing Address - Fax:
Practice Address - Street 1:5131 N CLASSEN BLVD
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73118-5258
Practice Address - Country:US
Practice Address - Phone:405-767-1126
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-11-15
Last Update Date:2011-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
Provider Identifiers
StateIdentifier IDID TypeIssuer
OKH081249623Medicaid