Provider Demographics
NPI:1407748676
Name:JOHNSON-GRANT, JADE ANGELIQUE
Entity type:Individual
Prefix:
First Name:JADE
Middle Name:ANGELIQUE
Last Name:JOHNSON-GRANT
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:JADE
Other - Middle Name:ANGELIQUE
Other - Last Name:LESTER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1002 SUMMERBROOK PL
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28540-3838
Mailing Address - Country:US
Mailing Address - Phone:910-777-9598
Mailing Address - Fax:
Practice Address - Street 1:1368 PINEY GREEN RD STE 4
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:NC
Practice Address - Zip Code:28546-4577
Practice Address - Country:US
Practice Address - Phone:910-777-9598
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-07-21
Last Update Date:2025-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC22716225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist