MEDICARE: JANE MARIE JOHNSON PEER CERTIFICATION

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	175T00000X	Peer Specialist
2	101YM0800X	Mental Health Counselor

General Provider Information

NPI Number	:	1114323706
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JANE MARIE JOHNSON PEER CERTIFICATION

Provider Business Mailing Address
First Line	:	4528 W CRAIG RD STE 150
Second Line	:
City	:	NORTH LAS VEGAS
State	:	NV
Zip	:	89032-2506
Country	:	US
Telephone Number	:	702-575-5662
Fax Number	:	702-645-0833

Provider Business Practice Location Address
First Line	:	4528 W CRAIG RD STE 150
Second Line	:
City	:	NORTH LAS VEGAS
State	:	NV
Zip	:	89032-2506
Country	:	US
Telephone Number	:	702-575-5662
Fax Number	:	702-645-0833

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	11/10/2014
Last Update Date	:	07/21/2022

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