Provider Demographics
NPI:1154776136
Name:JOHNSON, JENNA
Entity type:Individual
Prefix:
First Name:JENNA
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 1:125 VINCEWOOD DR
Mailing Address - Street 2:
Mailing Address - City:NICHOLASVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40356-9342
Mailing Address - Country:US
Mailing Address - Phone:859-312-1838
Mailing Address - Fax:
Practice Address - Street 1:2035 REGENCY RD STE 5
Practice Address - Street 2:
Practice Address - City:LEXINGTON
Practice Address - State:KY
Practice Address - Zip Code:40503-2333
Practice Address - Country:US
Practice Address - Phone:859-402-1553
Practice Address - Fax:859-514-6575
Is Sole Proprietor?:Yes
Enumeration Date:2016-04-27
Last Update Date:2016-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY3753235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist