MEDICARE: JACQUELINE M 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	101YP2500X	Professional Counselor

General Provider Information

NPI Number	:	1942771738
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JACQUELINE M JOHNSON

Provider Business Mailing Address
First Line	:	1304 E CARDEZA ST
Second Line	:
City	:	PHILA
State	:	PA
Zip	:	19119-1545
Country	:	US
Telephone Number	:	267-444-2735
Fax Number	:

Provider Business Practice Location Address
First Line	:	1304 E CARDEZA ST
Second Line	:
City	:	PHILA
State	:	PA
Zip	:	19119-1545
Country	:	US
Telephone Number	:	267-444-2735
Fax Number	:

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

Provider Enumeration Date	:	12/06/2018
Last Update Date	:	12/06/2018

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Directions to “ JACQUELINE M JOHNSON ” Practice Location

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