Healthcare Provider Details

I. General information

NPI: 1477329902
Provider Name (Legal Business Name): JEVON JOHNSON
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/27/2023
Last Update Date: 11/27/2023
Certification Date: 11/27/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

35425 W MICHIGAN AVE
WAYNE MI
48184-9800
US

IV. Provider business mailing address

PO BOX 7048
DEARBORN MI
48121-7048
US

V. Phone/Fax

Practice location:
  • Phone: 313-587-6940
  • Fax:
Mailing address:
  • Phone: 313-587-6940
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: