Healthcare Provider Details

I. General information

NPI: 1740023738
Provider Name (Legal Business Name): JILLIAN JOHNSON
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/17/2024
Last Update Date: 05/17/2025
Certification Date: 05/17/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

116 AGNES AVE
SANTA MARIA CA
93458-2838
US

IV. Provider business mailing address

733 N E ST APT F
LOMPOC CA
93436-4534
US

V. Phone/Fax

Practice location:
  • Phone: 805-457-3724
  • Fax:
Mailing address:
  • Phone: 805-298-7871
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code373H00000X
TaxonomyDay Training/Habilitation Specialist
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code175T00000X
TaxonomyPeer Specialist
License NumberMPSS-ZAMGNC
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: