Basic Information
| Provider Information | |||||||||
| NPI: | 1487718813 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | JOHNSON | ||||||||
| FirstName: | JANE | ||||||||
| MiddleName: | E | ||||||||
| NamePrefix: | MS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | LCSW | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2238 E GINTER ROAD | ||||||||
| Address2: | SUNNYSIDE UNIFIED SCHOOL DISTRICT NO 12 | ||||||||
| City: | TUSCON | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 95706 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5205452137 | ||||||||
| FaxNumber: | 5205452120 | ||||||||
| Practice Location | |||||||||
| Address1: | 2238 E GINTER ROAD | ||||||||
| Address2: | SUNNYSIDE UNIFIED SCHOOL DISTRICT NO 12 | ||||||||
| City: | TUSCON | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 95706 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5205452137 | ||||||||
| FaxNumber: | 5205452120 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/20/2006 | ||||||||
| LastUpdateDate: | 07/09/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | LCSW0556 | AZ | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
ID Information
| ID | Type | State | Issuer | Description | 583957 | 05 | AZ | MEDICAID |