Provider Demographics
NPI:1215708425
Name:WASHINGTON, JOHN
Entity type:Individual
Prefix:
First Name:JOHN
Middle Name:
Last Name:WASHINGTON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2647 EMERSON AVE S APT 11
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55408-1228
Mailing Address - Country:US
Mailing Address - Phone:612-310-6908
Mailing Address - Fax:
Practice Address - Street 1:3055 OLD HIGHWAY 8 STE 190
Practice Address - Street 2:
Practice Address - City:ST ANTHONY
Practice Address - State:MN
Practice Address - Zip Code:55418-2595
Practice Address - Country:US
Practice Address - Phone:612-345-7659
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-01-16
Last Update Date:2024-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician