Provider Demographics
NPI:1891852133
Name:JOHNSON, JESSICA BETH (MA, MFTI)
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:BETH
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:MA, MFTI
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:203 LOS BANOS AVE
Mailing Address - Street 2:
Mailing Address - City:WALNUT CREEK
Mailing Address - State:CA
Mailing Address - Zip Code:94598-3131
Mailing Address - Country:US
Mailing Address - Phone:925-788-3103
Mailing Address - Fax:
Practice Address - Street 1:390 40TH ST
Practice Address - Street 2:
Practice Address - City:OAKLAND
Practice Address - State:CA
Practice Address - Zip Code:94609-2633
Practice Address - Country:US
Practice Address - Phone:925-788-3103
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-03
Last Update Date:2010-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMFC 47746106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist