=====================================================
General NPI Number Information
=====================================================
NPI Number | 1225368996
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JANE T JOHNSON SLP
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/01/2010
-----------------------------------------------------
Last Update Date | 01/01/2010
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 22714 SOFIE RD
-----------------------------------------------------
City | MONROE
-----------------------------------------------------
State | WA
-----------------------------------------------------
Zip | 98272-7682
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 360-805-0323
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 22714 SOFIE RD
-----------------------------------------------------
City | MONROE
-----------------------------------------------------
State | WA
-----------------------------------------------------
Zip | 98272-7682
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 360-805-0323
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 235Z00000X
-----------------------------------------------------
Taxonomy Name | Speech-Language Pathologist
-----------------------------------------------------
License Number | LL 60117805
-----------------------------------------------------
License Number State | WA
-----------------------------------------------------