MEDICARE: MRS. JEANNETTE LYNN JOHNSON NA

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	103K00000X	Behavior Analyst	NV20131487332	NV

General Provider Information

NPI Number	:	1184054389
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. JEANNETTE LYNN JOHNSON NA

Provider Business Mailing Address
First Line	:	1009 RUSTRIDGE AVE
Second Line	:
City	:	NORTH LAS VEGAS
State	:	NV
Zip	:	89081-6658
Country	:	US
Telephone Number	:	855-239-3855
Fax Number	:

Provider Business Practice Location Address
First Line	:	1009 RUSTRIDGE AVE
Second Line	:
City	:	NORTH LAS VEGAS
State	:	NV
Zip	:	89081-6658
Country	:	US
Telephone Number	:	855-239-3855
Fax Number	:

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

Provider Enumeration Date	:	11/25/2013
Last Update Date	:	11/25/2013

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