Provider Demographics
NPI:1215444369
Name:JOHNSON, JORDAN LYNNE
Entity type:Individual
Prefix:
First Name:JORDAN
Middle Name:LYNNE
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:JORDAN
Other - Middle Name:LYNNE
Other - Last Name:JENSEN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:3771 STEFANI RD
Mailing Address - Street 2:
Mailing Address - City:CANTONMENT
Mailing Address - State:FL
Mailing Address - Zip Code:32533-7795
Mailing Address - Country:US
Mailing Address - Phone:850-607-6910
Mailing Address - Fax:
Practice Address - Street 1:4673 E HIGHWAY 20
Practice Address - Street 2:
Practice Address - City:NICEVILLE
Practice Address - State:FL
Practice Address - Zip Code:32578-9796
Practice Address - Country:US
Practice Address - Phone:850-897-0621
Practice Address - Fax:850-897-0621
Is Sole Proprietor?:Yes
Enumeration Date:2018-01-10
Last Update Date:2018-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRBT-17-33999106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician