Provider Demographics
NPI:1548077860
Name:JOHNSON, JACOB
Entity type:Individual
Prefix:
First Name:JACOB
Middle Name:
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6744 MAIN AVE
Mailing Address - Street 2:
Mailing Address - City:ORANGEVALE
Mailing Address - State:CA
Mailing Address - Zip Code:95662
Mailing Address - Country:US
Mailing Address - Phone:424-251-1961
Mailing Address - Fax:
Practice Address - Street 1:720 SUNRISE AVE
Practice Address - Street 2:
Practice Address - City:ROSEVILLE
Practice Address - State:CA
Practice Address - Zip Code:95661-4516
Practice Address - Country:US
Practice Address - Phone:424-251-1961
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-12-11
Last Update Date:2024-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health