Healthcare Provider Details

I. General information

NPI: 1114323706
Provider Name (Legal Business Name): JANE MARIE JOHNSON PEER CERTIFICATION
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/10/2014
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4528 W CRAIG RD STE 150
NORTH LAS VEGAS NV
89032-2506
US

IV. Provider business mailing address

4528 W CRAIG RD STE 150
NORTH LAS VEGAS NV
89032-2506
US

V. Phone/Fax

Practice location:
  • Phone: 702-575-5662
  • Fax: 702-645-0833
Mailing address:
  • Phone: 702-575-5662
  • Fax: 702-645-0833

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code175T00000X
TaxonomyPeer Specialist
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: