Provider Demographics
NPI:1427109552
Name:JOHNSON, JENNIFER WHITE (MD)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:WHITE
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:JENNIFER
Other - Middle Name:LOU ANN
Other - Last Name:WHITE
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:PO BOX 130
Mailing Address - Street 2:
Mailing Address - City:RATCLIFF
Mailing Address - State:AR
Mailing Address - Zip Code:72951-0130
Mailing Address - Country:US
Mailing Address - Phone:479-635-5300
Mailing Address - Fax:479-635-2010
Practice Address - Street 1:4900 KELLEY HIGHWAY
Practice Address - Street 2:
Practice Address - City:FORT SMITH
Practice Address - State:AR
Practice Address - Zip Code:72904-5000
Practice Address - Country:US
Practice Address - Phone:479-785-5700
Practice Address - Fax:479-785-5708
Is Sole Proprietor?:No
Enumeration Date:2007-01-16
Last Update Date:2010-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARE2929208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR143530001Medicaid
H43978Medicare UPIN
AR143530001Medicaid