Provider Demographics
NPI:1518403708
Name:JOHNSON, JAIME LEE (LMT, MMP)
Entity type:Individual
Prefix:MS
First Name:JAIME
Middle Name:LEE
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:LMT, MMP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:69 HARRINGTON RD
Mailing Address - Street 2:
Mailing Address - City:BROAD BROOK
Mailing Address - State:CT
Mailing Address - Zip Code:06016-9613
Mailing Address - Country:US
Mailing Address - Phone:860-805-9005
Mailing Address - Fax:
Practice Address - Street 1:42 BRIDGE ST
Practice Address - Street 2:
Practice Address - City:EAST WINDSOR
Practice Address - State:CT
Practice Address - Zip Code:06088-9679
Practice Address - Country:US
Practice Address - Phone:860-805-9005
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-01-11
Last Update Date:2017-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT005974225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist