Provider Demographics
NPI:1366087389
Name:JOHNSON, JAIDA ZHANE
Entity type:Individual
Prefix:
First Name:JAIDA
Middle Name:ZHANE
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5200 NELSON RD APT 616
Mailing Address - Street 2:
Mailing Address - City:LAKE CHARLES
Mailing Address - State:LA
Mailing Address - Zip Code:70605-0811
Mailing Address - Country:US
Mailing Address - Phone:501-316-9757
Mailing Address - Fax:
Practice Address - Street 1:1202 KIRKMAN ST STE C
Practice Address - Street 2:
Practice Address - City:LAKE CHARLES
Practice Address - State:LA
Practice Address - Zip Code:70601-5391
Practice Address - Country:US
Practice Address - Phone:501-316-9757
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-11-13
Last Update Date:2019-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator