Healthcare Provider Details

I. General information

NPI: 1205399870
Provider Name (Legal Business Name): TREMAYNA A JOHNSON
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/10/2019
Last Update Date: 01/09/2024
Certification Date: 01/09/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

425 E SANTA CLARA ST
SAN JOSE CA
95113-1936
US

IV. Provider business mailing address

602 NOKOMIS DR
SAN JOSE CA
95111-2547
US

V. Phone/Fax

Practice location:
  • Phone: 409-508-2253
  • Fax:
Mailing address:
  • Phone: 408-508-2253
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number StateNULL
# 3
Primary TaxonomyN
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: