Provider Demographics
NPI:1669255006
Name:JOHNS, SHANE M (DEDMIN, LMFT)
Entity type:Individual
Prefix:
First Name:SHANE
Middle Name:M
Last Name:JOHNS
Suffix:
Gender:M
Credentials:DEDMIN, LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:96331 MONTEGO BAY
Mailing Address - Street 2:
Mailing Address - City:FERNANDINA BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32034-8481
Mailing Address - Country:US
Mailing Address - Phone:904-557-0930
Mailing Address - Fax:
Practice Address - Street 1:2382 SADLER RD
Practice Address - Street 2:
Practice Address - City:FERNANDINA BEACH
Practice Address - State:FL
Practice Address - Zip Code:32034-4548
Practice Address - Country:US
Practice Address - Phone:904-469-7706
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-08-18
Last Update Date:2023-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist