Healthcare Provider Details

I. General information

NPI: 1083857312
Provider Name (Legal Business Name): KEM JACQUELINE JOHNSON MS, MED, CNS, LDN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/16/2009
Last Update Date: 06/07/2023
Certification Date: 06/07/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1111 N CHARLES ST
BALTIMORE MD
21201-5505
US

IV. Provider business mailing address

1111 N CHARLES ST
BALTIMORE MD
21201-5505
US

V. Phone/Fax

Practice location:
  • Phone: 410-837-2050
  • Fax:
Mailing address:
  • Phone: 410-837-2050
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberSC1018
License Number StateMD
# 2
Primary TaxonomyY
Taxonomy Code133N00000X
TaxonomyNutritionist
License NumberDX5837
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: