Provider Demographics
NPI:1043792831
Name:JOHNSTON, JENNIFER MARIE
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:MARIE
Last Name:JOHNSTON
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:PO BOX 92
Mailing Address - Street 2:
Mailing Address - City:FIRESTONE
Mailing Address - State:CO
Mailing Address - Zip Code:80520-0092
Mailing Address - Country:US
Mailing Address - Phone:970-342-8386
Mailing Address - Fax:
Practice Address - Street 1:2204 HOFFMAN DR STE A
Practice Address - Street 2:
Practice Address - City:LOVELAND
Practice Address - State:CO
Practice Address - Zip Code:80538-5035
Practice Address - Country:US
Practice Address - Phone:970-599-1014
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-08-29
Last Update Date:2018-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COLPC.0014840101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Single Specialty