Provider Demographics
NPI:1457192148
Name:JOHNSON, JAQUEZ TERELL (MBA)
Entity type:Individual
Prefix:MR
First Name:JAQUEZ
Middle Name:TERELL
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:MBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:113 DINNER LAKE AVE
Mailing Address - Street 2:
Mailing Address - City:LAKE WALES
Mailing Address - State:FL
Mailing Address - Zip Code:33859-2155
Mailing Address - Country:US
Mailing Address - Phone:662-769-4077
Mailing Address - Fax:
Practice Address - Street 1:113 DINNER LAKE AVE
Practice Address - Street 2:
Practice Address - City:LAKE WALES
Practice Address - State:FL
Practice Address - Zip Code:33859-2155
Practice Address - Country:US
Practice Address - Phone:662-769-4077
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-06-05
Last Update Date:2024-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator