Provider Demographics
NPI:1861251613
Name:JOHNSON, KIMBERLY JENINE (EDD)
Entity type:Individual
Prefix:DR
First Name:KIMBERLY
Middle Name:JENINE
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:EDD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11501 BALLYMORE
Mailing Address - Street 2:
Mailing Address - City:DUNLAP
Mailing Address - State:IL
Mailing Address - Zip Code:61525-8713
Mailing Address - Country:US
Mailing Address - Phone:163-045-2162
Mailing Address - Fax:
Practice Address - Street 1:11501 BALLYMORE
Practice Address - Street 2:
Practice Address - City:DUNLAP
Practice Address - State:IL
Practice Address - Zip Code:61525-8713
Practice Address - Country:US
Practice Address - Phone:630-452-1620
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-03-14
Last Update Date:2024-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes222Q00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDevelopmental Therapist