Provider Demographics
NPI:1063239572
Name:TYSON-JOHNSON, JAQUITSHA LA'KWONSHAY
Entity type:Individual
Prefix:MISS
First Name:JAQUITSHA
Middle Name:LA'KWONSHAY
Last Name:TYSON-JOHNSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:390 NE 191ST ST # 8584
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33179-3899
Mailing Address - Country:US
Mailing Address - Phone:772-485-2242
Mailing Address - Fax:
Practice Address - Street 1:2047 SW DANFORTH CIR
Practice Address - Street 2:
Practice Address - City:PALM CITY
Practice Address - State:FL
Practice Address - Zip Code:34990-7704
Practice Address - Country:US
Practice Address - Phone:772-485-2242
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-09-25
Last Update Date:2024-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL335E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier