Provider Demographics
NPI:1790187094
Name:JOHNSON, JEANINE (PSYD)
Entity type:Individual
Prefix:DR
First Name:JEANINE
Middle Name:
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 601422
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92160-1422
Mailing Address - Country:US
Mailing Address - Phone:877-840-6956
Mailing Address - Fax:619-383-6701
Practice Address - Street 1:5060 SHOREHAM PL
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92122-5903
Practice Address - Country:US
Practice Address - Phone:877-840-6956
Practice Address - Fax:619-383-6701
Is Sole Proprietor?:Yes
Enumeration Date:2014-09-18
Last Update Date:2025-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA29523103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist