Healthcare Provider Details

I. General information

NPI: 1649776899
Provider Name (Legal Business Name): AXELINE JANICKE MAISONET JOHNSON MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/04/2018
Last Update Date: 12/19/2025
Certification Date: 12/19/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4371 LATHAM ST STE 200
RIVERSIDE CA
92501-1731
US

IV. Provider business mailing address

415 N CAMDEN DRIVE STE 111 #724
BEVERLY HILLS CA
90210
US

V. Phone/Fax

Practice location:
  • Phone: 833-867-4642
  • Fax:
Mailing address:
  • Phone: 833-867-4642
  • Fax: 267-367-5763

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License NumberMD470729
License Number StatePA
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number179054
License Number StateCA
# 4
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License NumberW2736
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: