Provider Demographics
NPI:1740253905
Name:JOHNSON, JAMES D (PSYD)
Entity type:Individual
Prefix:DR
First Name:JAMES
Middle Name:D
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3475 N SARATOGA ST
Mailing Address - Street 2:
Mailing Address - City:OAK HARBOR
Mailing Address - State:WA
Mailing Address - Zip Code:98278-8800
Mailing Address - Country:US
Mailing Address - Phone:360-257-9877
Mailing Address - Fax:
Practice Address - Street 1:3475 N SARATOGA ST
Practice Address - Street 2:
Practice Address - City:OAK HARBOR
Practice Address - State:WA
Practice Address - Zip Code:98278-8800
Practice Address - Country:US
Practice Address - Phone:360-257-9877
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-02-08
Last Update Date:2013-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT362103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MT0492252Medicaid
MT0492252Medicaid