Healthcare Provider Details

I. General information

NPI: 1184180655
Provider Name (Legal Business Name): JACOB RYNE JOHNSON COUNSELOR, PROF
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/20/2019
Last Update Date: 12/04/2025
Certification Date: 12/04/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

16601 N 40TH ST STE 216
PHOENIX AZ
85032-3354
US

IV. Provider business mailing address

16601 N 40TH ST STE 216
PHOENIX AZ
85032-3354
US

V. Phone/Fax

Practice location:
  • Phone: 623-469-0606
  • Fax:
Mailing address:
  • Phone: 623-469-0606
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberLPC-17622
License Number StateAZ
# 2
Primary TaxonomyN
Taxonomy Code101Y00000X
TaxonomyCounselor
License NumberLPC-17622
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: