Provider Demographics
NPI:1427295112
Name:JOHNSON, JENNY L (MS, CCC-SLP)
Entity type:Individual
Prefix:
First Name:JENNY
Middle Name:L
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:MS, CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:152 E MAIN ST
Mailing Address - Street 2:STE. 110
Mailing Address - City:RIGBY
Mailing Address - State:ID
Mailing Address - Zip Code:83442-5266
Mailing Address - Country:US
Mailing Address - Phone:208-745-7101
Mailing Address - Fax:208-745-0068
Practice Address - Street 1:152 E MAIN ST
Practice Address - Street 2:SUITE 110
Practice Address - City:RIGBY
Practice Address - State:ID
Practice Address - Zip Code:83442-5266
Practice Address - Country:US
Practice Address - Phone:208-745-7101
Practice Address - Fax:208-745-0068
Is Sole Proprietor?:No
Enumeration Date:2009-01-16
Last Update Date:2009-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDSLP-1810235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist