Provider Demographics
NPI:1679821441
Name:JOHNSON, JAWAN M
Entity Type:Individual
Prefix:MR
First Name:JAWAN
Middle Name:M
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12601 N PENNSYLVANIA AVE
Mailing Address - Street 2:APT 440 S
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73120-9450
Mailing Address - Country:US
Mailing Address - Phone:405-833-6443
Mailing Address - Fax:
Practice Address - Street 1:12601 N PENNSYLVANIA AVE
Practice Address - Street 2:APT 440 S
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73120-9450
Practice Address - Country:US
Practice Address - Phone:405-833-6443
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-08-27
Last Update Date:2012-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health