Provider Demographics
NPI:1942771738
Name:JOHNSON, JACQUELINE M
Entity Type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:M
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 1:1304 E CARDEZA ST
Mailing Address - Street 2:
Mailing Address - City:PHILA
Mailing Address - State:PA
Mailing Address - Zip Code:19119-1545
Mailing Address - Country:US
Mailing Address - Phone:267-444-2735
Mailing Address - Fax:
Practice Address - Street 1:1304 E CARDEZA ST
Practice Address - Street 2:
Practice Address - City:PHILA
Practice Address - State:PA
Practice Address - Zip Code:19119-1545
Practice Address - Country:US
Practice Address - Phone:267-444-2735
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-12-06
Last Update Date:2018-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional