Provider Demographics
NPI:1427514397
Name:JOHNSON, JENNIFER DENISE (REGISTERED NURSE)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:DENISE
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:REGISTERED NURSE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1600 E REED RD
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:MS
Mailing Address - Zip Code:38703-7229
Mailing Address - Country:US
Mailing Address - Phone:662-580-0635
Mailing Address - Fax:662-580-0569
Practice Address - Street 1:1600 E REED RD
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:MS
Practice Address - Zip Code:38703-7229
Practice Address - Country:US
Practice Address - Phone:662-580-0635
Practice Address - Fax:662-580-0569
Is Sole Proprietor?:Yes
Enumeration Date:2019-02-15
Last Update Date:2022-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS878314163WC1500X, 163WM0705X, 163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
No163WC1500XNursing Service ProvidersRegistered NurseCommunity Health
No163WM0705XNursing Service ProvidersRegistered NurseMedical-Surgical