Healthcare Provider Details

I. General information

NPI: 1568219780
Provider Name (Legal Business Name): JEANETTE MARIE JOHNSON
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/06/2024
Last Update Date: 05/06/2024
Certification Date: 05/05/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1740 VICTORIA RD
CLEVELAND OH
44112-1415
US

IV. Provider business mailing address

1740 VICTORIA RD
CLEVELAND OH
44112-1415
US

V. Phone/Fax

Practice location:
  • Phone: 216-905-1638
  • Fax:
Mailing address:
  • Phone: 216-905-1638
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3747A0650X
TaxonomyAttendant Care Provider
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: