Provider Demographics
NPI:1124784996
Name:JOHNSON, JAMIE (IMH)
Entity type:Individual
Prefix:
First Name:JAMIE
Middle Name:
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:IMH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15928 DOVER CLIFFE DR
Mailing Address - Street 2:
Mailing Address - City:LUTZ
Mailing Address - State:FL
Mailing Address - Zip Code:33548-6122
Mailing Address - Country:US
Mailing Address - Phone:727-466-7451
Mailing Address - Fax:
Practice Address - Street 1:29149 CHAPEL PARK DR
Practice Address - Street 2:
Practice Address - City:WESLEY CHAPEL
Practice Address - State:FL
Practice Address - Zip Code:33543-4423
Practice Address - Country:US
Practice Address - Phone:813-575-8199
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-11-16
Last Update Date:2021-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLIMH15988101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health