Provider Demographics
NPI:1548990500
Name:JOHNSON, JONATHAN SIAKE SR
Entity type:Individual
Prefix:MR
First Name:JONATHAN
Middle Name:SIAKE
Last Name:JOHNSON
Suffix:SR
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 1:14056 E VASSAR AVE APT C-206
Mailing Address - Street 2:
Mailing Address - City:AURORA
Mailing Address - State:CO
Mailing Address - Zip Code:80014-2387
Mailing Address - Country:US
Mailing Address - Phone:719-679-7679
Mailing Address - Fax:
Practice Address - Street 1:14056 E VASSAR AVE APT C-206
Practice Address - Street 2:
Practice Address - City:AURORA
Practice Address - State:CO
Practice Address - Zip Code:80014
Practice Address - Country:US
Practice Address - Phone:719-679-7679
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-06-13
Last Update Date:2022-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CONONE103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
Provider Identifiers
StateIdentifier IDID TypeIssuer
CONONEOtherNONE