Provider Demographics
NPI:1720457773
Name:JOHNSON, KASSANDRA IRENE (MS)
Entity Type:Individual
Prefix:
First Name:KASSANDRA
Middle Name:IRENE
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1311 N 24TH ST
Mailing Address - Street 2:
Mailing Address - City:OMAHA
Mailing Address - State:NE
Mailing Address - Zip Code:68102-4010
Mailing Address - Country:US
Mailing Address - Phone:402-344-0441
Mailing Address - Fax:
Practice Address - Street 1:1311 N 24TH ST
Practice Address - Street 2:
Practice Address - City:OMAHA
Practice Address - State:NE
Practice Address - Zip Code:68102-4010
Practice Address - Country:US
Practice Address - Phone:402-344-0441
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-09-21
Last Update Date:2015-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE4732710825235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist