Provider Demographics
NPI:1700329489
Name:JOHNSON, JERMAINE (EDS)
Entity type:Individual
Prefix:MR
First Name:JERMAINE
Middle Name:
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:EDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5450 BRUCE B DOWNS BLVD SUITE 328
Mailing Address - Street 2:
Mailing Address - City:WESLEY CHAPEL
Mailing Address - State:FL
Mailing Address - Zip Code:33544
Mailing Address - Country:US
Mailing Address - Phone:813-361-5628
Mailing Address - Fax:
Practice Address - Street 1:5452 TREIG LN
Practice Address - Street 2:
Practice Address - City:WESLEY CHAPEL
Practice Address - State:FL
Practice Address - Zip Code:33545
Practice Address - Country:US
Practice Address - Phone:813-361-5628
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-11-29
Last Update Date:2019-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounseling