MEDICARE: JACQUELINE JOHNSON

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	164W00000X	Licensed Practical Nurse	286792-1	NY

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1215110705
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JACQUELINE JOHNSON

Provider Business Mailing Address
First Line	:	1039 E 212TH ST
Second Line	:
City	:	BRONX
State	:	NY
Zip	:	10469-1314
Country	:	US
Telephone Number	:	718-231-3364
Fax Number	:

Provider Business Practice Location Address
First Line	:	1039 E 212TH ST
Second Line	:
City	:	BRONX
State	:	NY
Zip	:	10469-1314
Country	:	US
Telephone Number	:	718-231-3364
Fax Number	:

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

Provider Enumeration Date	:	12/07/2007
Last Update Date	:	12/07/2007

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