Provider Demographics
NPI:1417195611
Name:JOHNSON, JACLYN
Entity type:Individual
Prefix:
First Name:JACLYN
Middle Name:
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:JACLYN
Other - Middle Name:
Other - Last Name:BURDAY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:14 LEAVITT RD
Mailing Address - Street 2:
Mailing Address - City:PITTSFIELD
Mailing Address - State:NH
Mailing Address - Zip Code:03263-3203
Mailing Address - Country:US
Mailing Address - Phone:603-709-8560
Mailing Address - Fax:
Practice Address - Street 1:14 LEAVITT RD
Practice Address - Street 2:
Practice Address - City:PITTSFIELD
Practice Address - State:NH
Practice Address - Zip Code:03263-3203
Practice Address - Country:US
Practice Address - Phone:603-709-8560
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-01-26
Last Update Date:2025-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No171M00000XOther Service ProvidersCase Manager/Care Coordinator
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NH99003227Medicaid
NE7706655Y0NH01OtherANTHEM
NE7706655Y0NH01OtherANTHEM