MEDICARE: JACQUELYNN S JOHNSON M.S.W.

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	104100000X	Social Worker	6801057927	MI

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	6801057927	OTHER	MI	MASTER'S SOCIAL WORKER CLINICAL AND MACRO LICENSE

General Provider Information

NPI Number	:	1588975320
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JACQUELYNN S JOHNSON M.S.W.

Provider Business Mailing Address
First Line	:	10635 OCEAN BEACH RD
Second Line	:
City	:	CLARKLAKE
State	:	MI
Zip	:	49234-9010
Country	:	US
Telephone Number	:	517-529-4928
Fax Number	:

Provider Business Practice Location Address
First Line	:	10635 OCEAN BEACH RD
Second Line	:
City	:	CLARKLAKE
State	:	MI
Zip	:	49234-9010
Country	:	US
Telephone Number	:	517-416-9186
Fax Number	:

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

Provider Enumeration Date	:	06/26/2010
Last Update Date	:	06/26/2010

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