Provider Demographics
NPI:1073973046
Name:JOHNSON-JACKSON, JENNIFER
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:
Last Name:JOHNSON-JACKSON
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 1:205 MOHAWK
Mailing Address - Street 2:
Mailing Address - City:BROWNSVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:42210
Mailing Address - Country:US
Mailing Address - Phone:270-901-5000
Mailing Address - Fax:270-842-5268
Practice Address - Street 1:205 MOHAWK
Practice Address - Street 2:
Practice Address - City:BROWNSVILLE
Practice Address - State:KY
Practice Address - Zip Code:42210
Practice Address - Country:US
Practice Address - Phone:270-901-5000
Practice Address - Fax:270-842-5268
Is Sole Proprietor?:No
Enumeration Date:2016-03-03
Last Update Date:2016-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst