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 1:1 WEST AVE STE 230
Mailing Address - Street 2:
Mailing Address - City:SARATOGA SPRINGS
Mailing Address - State:NY
Mailing Address - Zip Code:12866-6050
Mailing Address - Country:US
Mailing Address - Phone:518-583-5300
Mailing Address - Fax:518-370-7401
Practice Address - Street 1:1 WEST AVE STE 230
Practice Address - Street 2:
Practice Address - City:SARATOGA SPRINGS
Practice Address - State:NY
Practice Address - Zip Code:12866-6050
Practice Address - Country:US
Practice Address - Phone:518-583-5300
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-09-09
Last Update Date:2025-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY015812-1103T00000X
NY015812103TS0200X, 103TM1800X, 103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Multi-Specialty
No103T00000XBehavioral Health & Social Service ProvidersPsychologist
No103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool
No103TM1800XBehavioral Health & Social Service ProvidersPsychologistIntellectual & Developmental DisabilitiesGroup - Multi-Specialty