MEDICARE: SHANE M JOHNS D.ED.MIN., LMFT

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	106H00000X	Marriage & Family Therapist

General Provider Information

NPI Number	:	1669255006
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SHANE M JOHNS D.ED.MIN., LMFT

Provider Business Mailing Address
First Line	:	96331 MONTEGO BAY
Second Line	:
City	:	FERNANDINA BEACH
State	:	FL
Zip	:	32034-8481
Country	:	US
Telephone Number	:	904-557-0930
Fax Number	:

Provider Business Practice Location Address
First Line	:	2382 SADLER RD
Second Line	:
City	:	FERNANDINA BEACH
State	:	FL
Zip	:	32034-4548
Country	:	US
Telephone Number	:	904-469-7706
Fax Number	:

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

Provider Enumeration Date	:	08/18/2023
Last Update Date	:	08/18/2023

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