Basic Information
| Provider Information | |||||||||
| NPI: | 1780928556 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | JOHNSON | ||||||||
| FirstName: | JERROD | ||||||||
| MiddleName: | K. | ||||||||
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| Credential: | PSY.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1881 N UNIVERSITY DR STE 104 | ||||||||
| Address2: | |||||||||
| City: | CORAL SPRINGS | ||||||||
| State: | FL | ||||||||
| PostalCode: | 330716093 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9543400888 | ||||||||
| FaxNumber: | 9549543460 | ||||||||
| Practice Location | |||||||||
| Address1: | 1881 N UNIVERSITY DR STE 104 | ||||||||
| Address2: | |||||||||
| City: | CORAL SPRINGS | ||||||||
| State: | FL | ||||||||
| PostalCode: | 330716093 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9543400888 | ||||||||
| FaxNumber: | 9543460909 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/19/2012 | ||||||||
| LastUpdateDate: | 03/17/2018 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103TC0700X | PSY003599 | GA | N | Behavioral Health & Social Service Providers | Psychologist | Clinical | 103TC0700X | PY8744 | FL | Y | Behavioral Health & Social Service Providers | Psychologist | Clinical |
No ID Information.