Provider Demographics
NPI:1992001150
Name:JOHNSON, JENNIFER LYNN
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:LYNN
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 1:5134 W SPUR DR
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85083-1281
Mailing Address - Country:US
Mailing Address - Phone:623-580-0898
Mailing Address - Fax:
Practice Address - Street 1:4711 N 23RD AVE
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85015-3478
Practice Address - Country:US
Practice Address - Phone:602-242-2442
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-02-07
Last Update Date:2011-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool