Provider Demographics
NPI:1871462135
Name:JOHNSON, SHATAVIER
Entity type:Individual
Prefix:
First Name:SHATAVIER
Middle Name:
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6817 SOUTHPOINT PKWY STE 1201
Mailing Address - Street 2:STE 1201
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32216-6296
Mailing Address - Country:US
Mailing Address - Phone:336-512-4746
Mailing Address - Fax:
Practice Address - Street 1:6817 SOUTHPOINT PKWY STE 1201
Practice Address - Street 2:STE 1201
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32216-6296
Practice Address - Country:US
Practice Address - Phone:336-512-4746
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-11-04
Last Update Date:2025-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL104100000X
FLISW21463101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No104100000XBehavioral Health & Social Service ProvidersSocial Worker