Healthcare Provider Details

I. General information

NPI: 1063807683
Provider Name (Legal Business Name): DEBORAH JEAN JOHNSON
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/31/2015
Last Update Date: 11/21/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3625 14TH ST
RIVERSIDE CA
92501-3815
US

IV. Provider business mailing address

3625 14TH ST
RIVERSIDE CA
92501-3815
US

V. Phone/Fax

Practice location:
  • Phone: 951-955-1503
  • Fax:
Mailing address:
  • Phone: 951-955-1503
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number11959
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: