Provider Demographics
NPI:1427827757
Name:JOHNSON, JENNIFER MARIE (RN)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:MARIE
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17 PROVOST ST
Mailing Address - Street 2:
Mailing Address - City:BROCKTON
Mailing Address - State:MA
Mailing Address - Zip Code:02302-2829
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:17 PROVOST ST
Practice Address - Street 2:
Practice Address - City:BROCKTON
Practice Address - State:MA
Practice Address - Zip Code:02302-2829
Practice Address - Country:US
Practice Address - Phone:774-240-2935
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-12-28
Last Update Date:2023-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MARN2357596163WC1500X
MARN2347596163WP0809X, 163WA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WA0400XNursing Service ProvidersRegistered NurseAddiction (Substance Use Disorder)
No163WC1500XNursing Service ProvidersRegistered NurseCommunity Health
No163WP0809XNursing Service ProvidersRegistered NursePsychiatric/Mental Health, Adult