MEDICARE: JACQUELINE L 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	224Z00000X	Occupational Therapy Assistant	20517	FL

General Provider Information

NPI Number	:	1790632503
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JACQUELINE L JOHNSON

Provider Business Mailing Address
First Line	:	35 TOMOKA MEADOWS BLVD
Second Line	:
City	:	ORMOND BEACH
State	:	FL
Zip	:	32174-4432
Country	:	US
Telephone Number	:	386-843-9885
Fax Number	:

Provider Business Practice Location Address
First Line	:	35 TOMOKA MEADOWS BLVD
Second Line	:
City	:	ORMOND BEACH
State	:	FL
Zip	:	32174-4432
Country	:	US
Telephone Number	:	386-843-9885
Fax Number	:

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

Provider Enumeration Date	:	03/11/2026
Last Update Date	:	03/11/2026

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