Provider Demographics
NPI:1952659542
Name:JOHNSON, JERI W (MFC 51540)
Entity Type:Individual
Prefix:
First Name:JERI
Middle Name:W
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:MFC 51540
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:738 EAST MAIN STREET
Mailing Address - Street 2:
Mailing Address - City:VENTURA
Mailing Address - State:CA
Mailing Address - Zip Code:93001
Mailing Address - Country:US
Mailing Address - Phone:805-648-2805
Mailing Address - Fax:805-648-2805
Practice Address - Street 1:738 EAST MAIN STREET
Practice Address - Street 2:
Practice Address - City:VENTURA
Practice Address - State:CA
Practice Address - Zip Code:93001
Practice Address - Country:US
Practice Address - Phone:805-648-2805
Practice Address - Fax:805-648-2805
Is Sole Proprietor?:Yes
Enumeration Date:2012-08-29
Last Update Date:2012-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMFC 51540106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist