Provider Demographics
NPI:1093353393
Name:JOHNSON, JENNIFER (CPSW)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:CPSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:614 MCADOO ST STE B
Mailing Address - Street 2:
Mailing Address - City:T OR C
Mailing Address - State:NM
Mailing Address - Zip Code:87901-2706
Mailing Address - Country:US
Mailing Address - Phone:575-297-0171
Mailing Address - Fax:
Practice Address - Street 1:614 MCADOO ST STE B
Practice Address - Street 2:
Practice Address - City:T OR C
Practice Address - State:NM
Practice Address - Zip Code:87901-2706
Practice Address - Country:US
Practice Address - Phone:575-297-0171
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-12-17
Last Update Date:2020-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM1009175T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist