Provider Demographics
NPI:1922335967
Name:JOHNSON, PHILIP E (BS)
Entity type:Individual
Prefix:
First Name:PHILIP
Middle Name:E
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:BS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3410 1ST ST S LOWR
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32250-5921
Mailing Address - Country:US
Mailing Address - Phone:904-524-9490
Mailing Address - Fax:
Practice Address - Street 1:406 TOURNAMENT RD
Practice Address - Street 2:
Practice Address - City:PONTE VEDRA BEACH
Practice Address - State:FL
Practice Address - Zip Code:32082-3647
Practice Address - Country:US
Practice Address - Phone:904-534-6935
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-11-12
Last Update Date:2010-05-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst