Provider Demographics
NPI:1104462266
Name:JOHNSON-KING, JORDAN
Entity type:Individual
Prefix:
First Name:JORDAN
Middle Name:
Last Name:JOHNSON-KING
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 1:2500 SOUTHWOOD DR
Mailing Address - Street 2:
Mailing Address - City:PAINESVILLE
Mailing Address - State:OH
Mailing Address - Zip Code:44077-4957
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:29125 CHAGRIN BLVD
Practice Address - Street 2:
Practice Address - City:BEACHWOOD
Practice Address - State:OH
Practice Address - Zip Code:44122-4622
Practice Address - Country:US
Practice Address - Phone:216-292-3999
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-11-25
Last Update Date:2023-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator