Provider Demographics
NPI:1548683444
Name:JOHNSON, JAMAL HUSSEIN (CADC II)
Entity type:Individual
Prefix:
First Name:JAMAL
Middle Name:HUSSEIN
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:CADC II
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:621 CARNEGIE DR
Mailing Address - Street 2:
Mailing Address - City:SAN BERNARDINO
Mailing Address - State:CA
Mailing Address - Zip Code:92408-3536
Mailing Address - Country:US
Mailing Address - Phone:909-386-9740
Mailing Address - Fax:909-381-2172
Practice Address - Street 1:621 CARNEGIE DR
Practice Address - Street 2:
Practice Address - City:SAN BERNARDINO
Practice Address - State:CA
Practice Address - Zip Code:92408-3536
Practice Address - Country:US
Practice Address - Phone:909-386-9740
Practice Address - Fax:909-381-2172
Is Sole Proprietor?:Yes
Enumeration Date:2014-01-28
Last Update Date:2020-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA333901Medicaid
CA333903Medicaid