Provider Demographics
NPI:1891047221
Name:JOHNSON, JEANEANE ELIZABETH (COTA)
Entity Type:Individual
Prefix:
First Name:JEANEANE
Middle Name:ELIZABETH
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:COTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1207 RADIUS WAY
Mailing Address - Street 2:
Mailing Address - City:NEWPORT NEWS
Mailing Address - State:VA
Mailing Address - Zip Code:23602-9039
Mailing Address - Country:US
Mailing Address - Phone:901-237-3559
Mailing Address - Fax:
Practice Address - Street 1:140 BRIMLEY DR
Practice Address - Street 2:
Practice Address - City:FREDERICKSBURG
Practice Address - State:VA
Practice Address - Zip Code:22406-5103
Practice Address - Country:US
Practice Address - Phone:540-757-5432
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-10-09
Last Update Date:2012-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN1108224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant