Basic Information
| Provider Information | |||||||||
| NPI: | 1831610849 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | JOHNSON | ||||||||
| FirstName: | JEANINE | ||||||||
| MiddleName: | MARY | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1701 ZONAL AVE | ||||||||
| Address2: | |||||||||
| City: | LOS ANGELES | ||||||||
| State: | CA | ||||||||
| PostalCode: | 900331065 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7608123080 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1701 ZONAL AVE | ||||||||
| Address2: | |||||||||
| City: | LOS ANGELES | ||||||||
| State: | CA | ||||||||
| PostalCode: | 900331065 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3232236298 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/29/2017 | ||||||||
| LastUpdateDate: | 06/29/2017 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YA0400X | R1255110617 | CA | Y | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) |
No ID Information.