Provider Demographics
NPI:1972539690
Name:PREWETT, JOHANN NICHOLAS (PHD)
Entity Type:Individual
Prefix:
First Name:JOHANN
Middle Name:NICHOLAS
Last Name:PREWETT
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3720 BEACH BLVD
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32207-3814
Mailing Address - Country:US
Mailing Address - Phone:904-475-2039
Mailing Address - Fax:
Practice Address - Street 1:1726 KINGSLEY AVE
Practice Address - Street 2:SUITE 12
Practice Address - City:ORANGE PARK
Practice Address - State:FL
Practice Address - Zip Code:32073-4463
Practice Address - Country:US
Practice Address - Phone:904-269-6071
Practice Address - Fax:904-269-6642
Is Sole Proprietor?:No
Enumeration Date:2006-06-24
Last Update Date:2017-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPY 4331103T00000X, 103TC2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
No103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & Adolescent