Provider Demographics
NPI:1649169657
Name:JOHNSON, JENNIFER
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:500 8TH AVENUE, FRNT 3
Mailing Address - Street 2:#1630
Mailing Address - City:MANHATTAN
Mailing Address - State:NY
Mailing Address - Zip Code:10018
Mailing Address - Country:US
Mailing Address - Phone:631-579-4112
Mailing Address - Fax:
Practice Address - Street 1:33 HILLTOP LN
Practice Address - Street 2:
Practice Address - City:WHEATLEY HEIGHTS
Practice Address - State:NY
Practice Address - Zip Code:11798-1303
Practice Address - Country:US
Practice Address - Phone:631-579-4112
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-07-02
Last Update Date:2025-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
174200000X, 376J00000X, 332U00000X
NY00623941374U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332U00000XSuppliersHome Delivered Meals
No174200000XOther Service ProvidersMeals
No374U00000XNursing Service Related ProvidersHome Health Aide
No376J00000XNursing Service Related ProvidersHomemaker