Provider Demographics
NPI:1952193609
Name:JOHNSON, JANNETH
Entity type:Individual
Prefix:
First Name:JANNETH
Middle Name:
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 1:929 E FOOTHILL BLVD SPC 9
Mailing Address - Street 2:
Mailing Address - City:UPLAND
Mailing Address - State:CA
Mailing Address - Zip Code:91786-4038
Mailing Address - Country:US
Mailing Address - Phone:909-358-7916
Mailing Address - Fax:
Practice Address - Street 1:15437 ANACAPA RD STE 30
Practice Address - Street 2:
Practice Address - City:VICTORVILLE
Practice Address - State:CA
Practice Address - Zip Code:92392-2458
Practice Address - Country:US
Practice Address - Phone:909-358-7916
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-05-20
Last Update Date:2025-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAAPCC19125101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty