Provider Demographics
NPI:1700356680
Name:JOHNSON, JANINE A (MS CCC-SLP)
Entity Type:Individual
Prefix:
First Name:JANINE
Middle Name:A
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:MS CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:611 W. CHURCH ST.
Mailing Address - Street 2:
Mailing Address - City:ROSWELL
Mailing Address - State:NM
Mailing Address - Zip Code:88203-4209
Mailing Address - Country:US
Mailing Address - Phone:469-401-8687
Mailing Address - Fax:
Practice Address - Street 1:1090 MED PARK DR.
Practice Address - Street 2:
Practice Address - City:LAS CRUCES
Practice Address - State:NM
Practice Address - Zip Code:88005-3236
Practice Address - Country:US
Practice Address - Phone:575-523-7243
Practice Address - Fax:575-525-5641
Is Sole Proprietor?:No
Enumeration Date:2018-12-04
Last Update Date:2022-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX409142355S0801X
NMSLP7034235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
No2355S0801XSpeech, Language and Hearing Service ProvidersSpecialist/TechnologistSpeech-Language Assistant