Provider Demographics
NPI:1588944813
Name:JOHNSON, STEPHANIE JO ANN (PSYD)
Entity type:Individual
Prefix:DR
First Name:STEPHANIE
Middle Name:JO ANN
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:DR
Other - First Name:STEPHANIE
Other - Middle Name:JO ANN
Other - Last Name:LICKISS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PSYD
Mailing Address - Street 1:4001 STATE HIGHWAY 104
Mailing Address - Street 2:
Mailing Address - City:IONE
Mailing Address - State:CA
Mailing Address - Zip Code:95640
Mailing Address - Country:US
Mailing Address - Phone:209-274-4911
Mailing Address - Fax:
Practice Address - Street 1:4001 STATE HIGHWAY 104
Practice Address - Street 2:
Practice Address - City:IONE
Practice Address - State:CA
Practice Address - Zip Code:95640
Practice Address - Country:US
Practice Address - Phone:209-274-4911
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-08-17
Last Update Date:2022-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY29508103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical