Provider Demographics
NPI:1265884019
Name:ANCHETA, JOHANNA JACQUELINE
Entity type:Individual
Prefix:
First Name:JOHANNA
Middle Name:JACQUELINE
Last Name:ANCHETA
Suffix:
Gender:U
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:57 ORCHARD ST
Mailing Address - Street 2:
Mailing Address - City:ELIZABETH
Mailing Address - State:NJ
Mailing Address - Zip Code:07208-3603
Mailing Address - Country:US
Mailing Address - Phone:908-230-7478
Mailing Address - Fax:
Practice Address - Street 1:5333 PUAHIA PL
Practice Address - Street 2:
Practice Address - City:HONOLULU
Practice Address - State:HI
Practice Address - Zip Code:96821-1543
Practice Address - Country:US
Practice Address - Phone:808-343-0093
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-07-05
Last Update Date:2024-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJA58664067159892390200000X
MI68011169761041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program