Provider Demographics
NPI:1851638381
Name:JOHNSON, JANE M (MS, CCC-SLP)
Entity Type:Individual
Prefix:
First Name:JANE
Middle Name:M
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:MS, CCC-SLP
Other - Prefix:
Other - First Name:JANE
Other - Middle Name:
Other - Last Name:WAGNER
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:9300 W STOCKTON BLVD STE 200
Mailing Address - Street 2:
Mailing Address - City:ELK GROVE
Mailing Address - State:CA
Mailing Address - Zip Code:95758-8070
Mailing Address - Country:US
Mailing Address - Phone:916-896-1144
Mailing Address - Fax:916-896-1145
Practice Address - Street 1:9300 W STOCKTON BLVD STE 200
Practice Address - Street 2:
Practice Address - City:ELK GROVE
Practice Address - State:CA
Practice Address - Zip Code:95758-8070
Practice Address - Country:US
Practice Address - Phone:916-896-1144
Practice Address - Fax:916-896-1146
Is Sole Proprietor?:No
Enumeration Date:2013-01-03
Last Update Date:2020-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA13359235Z00000X
CASP 13359235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1851638381Medicaid