Provider Demographics
NPI:1487363669
Name:JOHNSON, SHANNON JANIECE (ACSW)
Entity type:Individual
Prefix:
First Name:SHANNON
Middle Name:JANIECE
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:ACSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3420 FINNIAN WAY UNIT 122
Mailing Address - Street 2:
Mailing Address - City:DUBLIN
Mailing Address - State:CA
Mailing Address - Zip Code:94568-4534
Mailing Address - Country:US
Mailing Address - Phone:510-493-5722
Mailing Address - Fax:
Practice Address - Street 1:5325 BRODER BLVD
Practice Address - Street 2:
Practice Address - City:DUBLIN
Practice Address - State:CA
Practice Address - Zip Code:94568-3309
Practice Address - Country:US
Practice Address - Phone:925-560-5947
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-11-16
Last Update Date:2022-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA1100911041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical