Healthcare Provider Details

I. General information

NPI: 1366061632
Provider Name (Legal Business Name): JAHVASHA JANICE MONIQUE JOHNSON
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/15/2020
Last Update Date: 04/15/2020
Certification Date: 04/15/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

200 WYNN WAY APT C
COLUMBIA SC
29210-2912
US

IV. Provider business mailing address

200 WYNN WAY APT C
COLUMBIA SC
29210-2912
US

V. Phone/Fax

Practice location:
  • Phone: 803-915-4674
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code374J00000X
TaxonomyDoula
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: