Basic Information
| Provider Information | |||||||||
| NPI: | 1710955265 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | JOHNSEN | ||||||||
| FirstName: | JAMES | ||||||||
| MiddleName: | A | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5520 CHEROKEE AVE | ||||||||
| Address2: | SUITE 215 | ||||||||
| City: | ALEXANDRIA | ||||||||
| State: | VA | ||||||||
| PostalCode: | 223122319 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7039148000 | ||||||||
| FaxNumber: | 7036423487 | ||||||||
| Practice Location | |||||||||
| Address1: | 2800 S SHIRLINGTON RD | ||||||||
| Address2: | SUITE 102 | ||||||||
| City: | ARLINGTON | ||||||||
| State: | VA | ||||||||
| PostalCode: | 222063601 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7039148000 | ||||||||
| FaxNumber: | 7036423487 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/10/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | X | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208100000X | 0101045781 | VA | Y | Allopathic & Osteopathic Physicians | Physical Medicine & Rehabilitation |
ID Information
| ID | Type | State | Issuer | Description | 6058230 | 05 | VA | MEDICAID |