Healthcare Provider Details

I. General information

NPI: 1457268005
Provider Name (Legal Business Name): JACQUELINE JOHNSON
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/27/2026
Last Update Date: 08/27/2026
Certification Date: 08/27/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

914 EDISON AVE
LEHIGH ACRES FL
33972-8027
US

IV. Provider business mailing address

914 EDISON AVE
LEHIGH ACRES FL
33972-8027
US

V. Phone/Fax

Practice location:
  • Phone: 786-337-1792
  • Fax:
Mailing address:
  • Phone: 786-337-1792
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number17997
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: