Provider Demographics
NPI:1992105399
Name:JOHNSON, JULIE RENAE (LAC)
Entity type:Individual
Prefix:
First Name:JULIE
Middle Name:RENAE
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6031 S ELLIS AVE
Mailing Address - Street 2:W531
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60637-2348
Mailing Address - Country:US
Mailing Address - Phone:773-991-9455
Mailing Address - Fax:
Practice Address - Street 1:70 E LAKE ST
Practice Address - Street 2:SUITE 630
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60601-5959
Practice Address - Country:US
Practice Address - Phone:773-991-9455
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-09-04
Last Update Date:2014-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL198001219171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist