Provider Demographics
NPI:1447032248
Name:JOHNSON, EMILY DUNN
Entity type:Individual
Prefix:
First Name:EMILY
Middle Name:DUNN
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:130 BURNETT CT UNIT 109
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32259-6995
Mailing Address - Country:US
Mailing Address - Phone:904-652-3435
Mailing Address - Fax:
Practice Address - Street 1:12735 GRAN BAY PKWY W STE 204
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32258-4499
Practice Address - Country:US
Practice Address - Phone:888-557-6421
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-10-17
Last Update Date:2023-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician