MEDICARE: MONICA L JETER JOHNSON PHD

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	103T00000X	Psychologist	3-0561	TX

General Provider Information

NPI Number	:	1851392583
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MONICA L JETER JOHNSON PHD

Provider Business Mailing Address
First Line	:	5501 BRYAN ST
Second Line	:
City	:	DALLAS
State	:	TX
Zip	:	75206-8103
Country	:	US
Telephone Number	:	214-828-2603
Fax Number	:	214-828-4954

Provider Business Practice Location Address
First Line	:	5501 BRYAN ST
Second Line	:
City	:	DALLAS
State	:	TX
Zip	:	75206-8103
Country	:	US
Telephone Number	:	214-828-2603
Fax Number	:	214-828-4954

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

Provider Enumeration Date	:	08/03/2005
Last Update Date	:	07/08/2007

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