Provider Demographics
NPI:1437550571
Name:JOHNSON, JACQUELINE (PSYD)
Entity type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:500 BALLTOWN RD
Mailing Address - Street 2:
Mailing Address - City:SCHENECTADY
Mailing Address - State:NY
Mailing Address - Zip Code:12304-2247
Mailing Address - Country:US
Mailing Address - Phone:518-388-0425
Mailing Address - Fax:518-370-7401
Practice Address - Street 1:2592 WESTERN AVE STE 200
Practice Address - Street 2:
Practice Address - City:ALTAMONT
Practice Address - State:NY
Practice Address - Zip Code:12009-9401
Practice Address - Country:US
Practice Address - Phone:518-595-3104
Practice Address - Fax:855-593-6511
Is Sole Proprietor?:Yes
Enumeration Date:2014-09-09
Last Update Date:2023-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY015812-1103T00000X
NY015812103TC0700X, 103TS0200X, 103TM1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TM1800XBehavioral Health & Social Service ProvidersPsychologistIntellectual & Developmental DisabilitiesGroup - Multi-Specialty
No103T00000XBehavioral Health & Social Service ProvidersPsychologist
No103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool