Provider Demographics
NPI:1386466654
Name:JOHNSON, JENNIFER CAMPBELL (MS, RDN, LDN, IFNCP)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:CAMPBELL
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:MS, RDN, LDN, IFNCP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1229 SHINING WATER LN
Mailing Address - Street 2:
Mailing Address - City:CREEDMOOR
Mailing Address - State:NC
Mailing Address - Zip Code:27522-7246
Mailing Address - Country:US
Mailing Address - Phone:919-632-5283
Mailing Address - Fax:
Practice Address - Street 1:8801 FAST PARK DR STE 301
Practice Address - Street 2:
Practice Address - City:RALEIGH
Practice Address - State:NC
Practice Address - Zip Code:27617-4853
Practice Address - Country:US
Practice Address - Phone:910-663-5166
Practice Address - Fax:888-856-3502
Is Sole Proprietor?:No
Enumeration Date:2024-10-29
Last Update Date:2024-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCL007258133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered