Provider Demographics
NPI:1174166532
Name:JOHNSON, JENNIFER
Entity type:Individual
Prefix:MRS
First Name:JENNIFER
Middle Name:
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 1:4355 HIGH BRIDGE RD
Mailing Address - Street 2:
Mailing Address - City:QUINCY
Mailing Address - State:FL
Mailing Address - Zip Code:32351-6128
Mailing Address - Country:US
Mailing Address - Phone:850-322-5980
Mailing Address - Fax:850-364-4836
Practice Address - Street 1:4355 HIGH BRIDGE RD
Practice Address - Street 2:
Practice Address - City:QUINCY
Practice Address - State:FL
Practice Address - Zip Code:32351-6128
Practice Address - Country:US
Practice Address - Phone:850-322-5980
Practice Address - Fax:850-364-4836
Is Sole Proprietor?:Yes
Enumeration Date:2019-10-17
Last Update Date:2019-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor