Provider Demographics
NPI:1396153169
Name:JOHNSON, CLARENDA
Entity type:Individual
Prefix:MRS
First Name:CLARENDA
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:PO BOX 7164
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32238-0164
Mailing Address - Country:US
Mailing Address - Phone:904-651-4083
Mailing Address - Fax:
Practice Address - Street 1:9064 CASTLE BLVD
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32208-1602
Practice Address - Country:US
Practice Address - Phone:904-651-4083
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-07-24
Last Update Date:2014-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
374U00000X
FL233614376J00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes376J00000XNursing Service Related ProvidersHomemaker
No374U00000XNursing Service Related ProvidersHome Health Aide
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL233614OtherAHCA STATE LICENSE