Healthcare Provider Details

I. General information

NPI: 1205231628
Provider Name (Legal Business Name): JELANI JOHNSON-BRISCOE
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/28/2014
Last Update Date: 10/28/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

300 ILENE ST.
MARTINEZ CA
94553
US

IV. Provider business mailing address

1239 HALSEY
VALLEJO CA
94590
US

V. Phone/Fax

Practice location:
  • Phone: 925-313-7980
  • Fax:
Mailing address:
  • Phone: 925-917-0187
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: