Provider Demographics
NPI:1669947966
Name:JOHANSEN, JAMES KRISTOFF
Entity type:Individual
Prefix:
First Name:JAMES
Middle Name:KRISTOFF
Last Name:JOHANSEN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3767 CENTRAL AVE
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92105-2506
Mailing Address - Country:US
Mailing Address - Phone:619-278-0777
Mailing Address - Fax:
Practice Address - Street 1:6450 W SUNSET BLVD # 1255
Practice Address - Street 2:
Practice Address - City:HOLLYWOOD
Practice Address - State:CA
Practice Address - Zip Code:90028-7315
Practice Address - Country:US
Practice Address - Phone:619-359-9783
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-10-12
Last Update Date:2025-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAASW75667104100000X
CALCSW978821041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker