Provider Demographics
NPI:1841407574
Name:JOHNSON, JOSEPH ETHAN (BA)
Entity Type:Individual
Prefix:
First Name:JOSEPH
Middle Name:ETHAN
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:BA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1061 FRUIT COVE RD
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32259-3151
Mailing Address - Country:US
Mailing Address - Phone:904-651-6975
Mailing Address - Fax:
Practice Address - Street 1:390 PARK ST
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32204-2342
Practice Address - Country:US
Practice Address - Phone:904-899-6300
Practice Address - Fax:904-899-6380
Is Sole Proprietor?:No
Enumeration Date:2007-05-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor