MEDICARE: JACOB RYNE JOHNSON COUNSELOR, PROF

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YP2500X	Professional Counselor	LPC-17622	AZ
2	101Y00000X	Counselor	LPC-17622	AZ

General Provider Information

NPI Number	:	1184180655
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JACOB RYNE JOHNSON COUNSELOR, PROF

Provider Business Mailing Address
First Line	:	16601 N 40TH ST STE 216
Second Line	:
City	:	PHOENIX
State	:	AZ
Zip	:	85032-3354
Country	:	US
Telephone Number	:	623-469-0606
Fax Number	:

Provider Business Practice Location Address
First Line	:	16601 N 40TH ST STE 216
Second Line	:
City	:	PHOENIX
State	:	AZ
Zip	:	85032-3354
Country	:	US
Telephone Number	:	623-469-0606
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	02/20/2019
Last Update Date	:	12/04/2025

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