Provider Demographics
NPI:1790406700
Name:JOHNSON, BARBARA JEAN
Entity Type:Individual
Prefix:
First Name:BARBARA
Middle Name:JEAN
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 1:6248 HOLLY BAY DR
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32211-3932
Mailing Address - Country:US
Mailing Address - Phone:904-535-4113
Mailing Address - Fax:
Practice Address - Street 1:6248 HOLLY BAY DR
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32211-3932
Practice Address - Country:US
Practice Address - Phone:904-535-4113
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-09-07
Last Update Date:2022-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251C00000XAgenciesDay Training, Developmentally Disabled Services
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL87-2962765Medicaid