Provider Demographics
NPI:1396959664
Name:JOHNSON, JACQUELINE KAY (EDD)
Entity type:Individual
Prefix:DR
First Name:JACQUELINE
Middle Name:KAY
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:EDD
Other - Prefix:DR
Other - First Name:J.
Other - Middle Name:KAY
Other - Last Name:JOHNSON
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:EDD
Mailing Address - Street 1:PO BOX 1394
Mailing Address - Street 2:
Mailing Address - City:FLAGSTAFF
Mailing Address - State:AZ
Mailing Address - Zip Code:86002-1394
Mailing Address - Country:US
Mailing Address - Phone:928-774-4313
Mailing Address - Fax:
Practice Address - Street 1:416 N KENDRICK ST
Practice Address - Street 2:
Practice Address - City:FLAGSTAFF
Practice Address - State:AZ
Practice Address - Zip Code:86001-1598
Practice Address - Country:US
Practice Address - Phone:928-774-9123
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-09
Last Update Date:2007-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ1104103T00000X
AZ103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered103T00000XBehavioral Health & Social Service ProvidersPsychologist
Not Answered103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool