Healthcare Provider Details

I. General information

NPI: 1386094738
Provider Name (Legal Business Name): JACLYN JOHNSON
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/16/2016
Last Update Date: 10/10/2025
Certification Date: 10/10/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

18 MDG UNIT 5268
APO AP
96368-5217
US

IV. Provider business mailing address

18 MDG UNIT 5268 OPC 80 BOX 5217
APO AP
96368-5217
US

V. Phone/Fax

Practice location:
  • Phone: 544-634-3272
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number12267022-3501
License Number StateUT
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: