Healthcare Provider Details

I. General information

NPI: 1194704874
Provider Name (Legal Business Name): KISHA D JOHNSON MD, CGC
Entity Type: Individual
Gender: Female
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 01/11/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1750 W HARRISON ST 1507 JELKE
CHICAGO IL
60612-3825
US

IV. Provider business mailing address

3802 W CONGRESS PKWY
CHICAGO IL
60624-3101
US

V. Phone/Fax

Practice location:
  • Phone: 312-942-6298
  • Fax: 312-942-2857
Mailing address:
  • Phone: 410-908-0683
  • Fax: 312-942-2857

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code170300000X
TaxonomyGenetic Counselor (M.S.)
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: