Provider Demographics
NPI:1972014223
Name:JOHNSON, JUDITH
Entity Type:Individual
Prefix:
First Name:JUDITH
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 1:2828 FOREST LN STE 1102
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75234-7500
Mailing Address - Country:US
Mailing Address - Phone:469-231-2621
Mailing Address - Fax:214-666-3825
Practice Address - Street 1:2828 FOREST LN STE 1143
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75234
Practice Address - Country:US
Practice Address - Phone:469-231-2621
Practice Address - Fax:214-666-3825
Is Sole Proprietor?:Yes
Enumeration Date:2017-10-13
Last Update Date:2018-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX253Z00000X, 374U00000X
374U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes374U00000XNursing Service Related ProvidersHome Health AideGroup - Single Specialty
No253Z00000XAgenciesIn Home Supportive CareGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX$$$$$$$$$Medicaid