Healthcare Provider Details

I. General information

NPI: 1144251471
Provider Name (Legal Business Name): JOHNSON CHANG PSYD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/05/2006
Last Update Date: 04/25/2025
Certification Date: 04/25/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9040 JACKSON AVE
TACOMA WA
98431-1336
US

IV. Provider business mailing address

9040A JACKSON AVE
JOINT BASE LEWIS MCCHORD WA
98431-1336
US

V. Phone/Fax

Practice location:
  • Phone: 253-982-5709
  • Fax:
Mailing address:
  • Phone: 253-982-5709
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103T00000X
TaxonomyPsychologist
License NumberPSY19706
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code103TF0200X
TaxonomyForensic Psychologist
License NumberPSY
License Number StateCA
# 3
Primary TaxonomyN
Taxonomy Code103TP2701X
TaxonomyGroup Psychotherapy Psychologist
License NumberPSY19706
License Number StateCA
# 4
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License NumberPY00003607
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: