Provider Demographics
NPI:1083715999
Name:JOHNSON, JEANNINE S (MD)
Entity Type:Individual
Prefix:DR
First Name:JEANNINE
Middle Name:S
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:JEANNINE
Other - Middle Name:S
Other - Last Name:BROWN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:3185 NW BAUER WOODS DR
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97229-3685
Mailing Address - Country:US
Mailing Address - Phone:503-690-0805
Mailing Address - Fax:
Practice Address - Street 1:19400 NW EVERGREEN PWY
Practice Address - Street 2:
Practice Address - City:HILLSBORO
Practice Address - State:OR
Practice Address - Zip Code:97124
Practice Address - Country:US
Practice Address - Phone:503-645-2762
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD22433208000000X
WAMD00040952208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics