Healthcare Provider Details

I. General information

NPI: 1821840133
Provider Name (Legal Business Name): JACQUELINE JOHNSON
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/02/2024
Last Update Date: 04/02/2024
Certification Date: 04/02/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

503 GREENWOOD AVE
CAMBRIDGE MD
21613-1407
US

IV. Provider business mailing address

2915 WINCHESTER ST
BALTIMORE MD
21216-4243
US

V. Phone/Fax

Practice location:
  • Phone: 443-848-3257
  • Fax:
Mailing address:
  • Phone: 443-848-3257
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251E00000X
TaxonomyHome Health Agency
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code3747P1801X
TaxonomyPersonal Care Attendant
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: