Healthcare Provider Details

I. General information

NPI: 1811673080
Provider Name (Legal Business Name): MRS. KATRINA JEAN JOHNSON
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/23/2023
Last Update Date: 09/08/2023
Certification Date: 09/08/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2085 RUSTIN AVE STE 5
RIVERSIDE CA
92507-2498
US

IV. Provider business mailing address

6978 BUCHANAN AVE
SAN BERNARDINO CA
92404-6126
US

V. Phone/Fax

Practice location:
  • Phone: 951-686-4357
  • Fax:
Mailing address:
  • Phone: 909-380-3462
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number103155
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: