Healthcare Provider Details

I. General information

NPI: 1225856024
Provider Name (Legal Business Name): JAYCI L JOHNSON
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/30/2024
Last Update Date: 08/17/2026
Certification Date: 08/17/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3921 PINTAIL DR STE B
SPRINGFIELD IL
62711-6738
US

IV. Provider business mailing address

3921 PINTAIL DR STE B
SPRINGFIELD IL
62711-6738
US

V. Phone/Fax

Practice location:
  • Phone: 502-297-0133
  • Fax:
Mailing address:
  • Phone: 502-297-0133
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number152003611
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: