Provider Demographics
NPI:1942605092
Name:JOHNSON, JOSEPHINE
Entity Type:Individual
Prefix:MRS
First Name:JOSEPHINE
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 1:14900 ARTESIAN AVE
Mailing Address - Street 2:
Mailing Address - City:HARVEY
Mailing Address - State:IL
Mailing Address - Zip Code:60426-1306
Mailing Address - Country:US
Mailing Address - Phone:708-331-5106
Mailing Address - Fax:708-333-7107
Practice Address - Street 1:14900 ARTESIAN AVE
Practice Address - Street 2:
Practice Address - City:HARVEY
Practice Address - State:IL
Practice Address - Zip Code:60426-1306
Practice Address - Country:US
Practice Address - Phone:708-331-5106
Practice Address - Fax:708-333-7107
Is Sole Proprietor?:Yes
Enumeration Date:2014-10-31
Last Update Date:2014-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL343900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes343900000XTransportation ServicesNon-emergency Medical Transport (VAN)
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL35-2194918Medicaid