Healthcare Provider Details

I. General information

NPI: 1922894880
Provider Name (Legal Business Name): KENNETH D JOHNSON
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/17/2025
Last Update Date: 06/24/2026
Certification Date: 06/24/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13300 E HIGHWAY 20
CLEARLAKE OAKS CA
95423-9436
US

IV. Provider business mailing address

PO BOX 1024
LUCERNE CA
95458-1024
US

V. Phone/Fax

Practice location:
  • Phone: 707-998-0310
  • Fax:
Mailing address:
  • Phone: 707-274-9101
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License NumberMPSS-YDOIKM
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: