Healthcare Provider Details

I. General information

NPI: 1922096932
Provider Name (Legal Business Name): JEFFREY FORDHAM JOHNS M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/12/2005
Last Update Date: 11/01/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2640 MARTIN LUTHER KING JR WAY
BERKELEY CA
94704-3238
US

IV. Provider business mailing address

2640 MARTIN LUTHER KING JR WAY
BERKELEY CA
94704-3238
US

V. Phone/Fax

Practice location:
  • Phone: 510-981-5290
  • Fax: 510-981-5265
Mailing address:
  • Phone: 510-981-5290
  • Fax: 510-981-5265

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License NumberA93824
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number45624-020
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: