Provider Demographics
NPI:1811728959
Name:JOHNSON, KEJUAN MARQUEE' (LMT)
Entity type:Individual
Prefix:MR
First Name:KEJUAN
Middle Name:MARQUEE'
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8504 16TH ST APT 504
Mailing Address - Street 2:
Mailing Address - City:SILVER SPRING
Mailing Address - State:MD
Mailing Address - Zip Code:20910-5913
Mailing Address - Country:US
Mailing Address - Phone:202-926-6086
Mailing Address - Fax:
Practice Address - Street 1:13992 BALTIMORE AVE STE 201A
Practice Address - Street 2:
Practice Address - City:LAUREL
Practice Address - State:MD
Practice Address - Zip Code:20707-5010
Practice Address - Country:US
Practice Address - Phone:301-953-0256
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-08-12
Last Update Date:2024-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDM06684225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist