Healthcare Provider Details

I. General information

NPI: 1093284382
Provider Name (Legal Business Name): JACK LEE JOHNSON II
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/16/2018
Last Update Date: 11/16/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1680 NORTH FAIR OAKS
PASADENA CA
91104
US

IV. Provider business mailing address

1680 N FAIR OAKS AVE
PASADENA CA
91103-1642
US

V. Phone/Fax

Practice location:
  • Phone: 210-241-0481
  • Fax:
Mailing address:
  • Phone: 626-798-0884
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: