Provider Demographics
NPI:1740795145
Name:OWENS-JOHNSON, EZERA NICOLE
Entity Type:Individual
Prefix:
First Name:EZERA
Middle Name:NICOLE
Last Name:OWENS-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 1:4701 WAGON GAP RD
Mailing Address - Street 2:
Mailing Address - City:KILLEEN
Mailing Address - State:TX
Mailing Address - Zip Code:76542-8324
Mailing Address - Country:US
Mailing Address - Phone:832-398-8641
Mailing Address - Fax:
Practice Address - Street 1:4701 WAGON GAP RD
Practice Address - Street 2:
Practice Address - City:KILLEEN
Practice Address - State:TX
Practice Address - Zip Code:76542-8324
Practice Address - Country:US
Practice Address - Phone:832-398-8641
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-12-06
Last Update Date:2017-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician