Provider Demographics
NPI:1821460999
Name:JOHNSON, JALEESA
Entity Type:Individual
Prefix:
First Name:JALEESA
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 1:506 MANCHESTER EXPRESSWAY
Mailing Address - Street 2:A. 13&14
Mailing Address - City:COLUMBUS
Mailing Address - State:GA
Mailing Address - Zip Code:31904
Mailing Address - Country:US
Mailing Address - Phone:706-653-9343
Mailing Address - Fax:
Practice Address - Street 1:506 MANCHESTER EXPY
Practice Address - Street 2:A. 13&14
Practice Address - City:COLUMBUS
Practice Address - State:GA
Practice Address - Zip Code:31904-6444
Practice Address - Country:US
Practice Address - Phone:706-653-9343
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-10-28
Last Update Date:2015-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251C00000XAgenciesDay Training, Developmentally Disabled Services