Provider Demographics
NPI:1104358779
Name:JOHNSON, ANNA
Entity Type:Individual
Prefix:
First Name:ANNA
Middle Name:
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 1:97 WILDWOOD LN
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:TN
Mailing Address - Zip Code:38301-3428
Mailing Address - Country:US
Mailing Address - Phone:731-402-0257
Mailing Address - Fax:
Practice Address - Street 1:597 W FOREST AVE
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:TN
Practice Address - Zip Code:38301-3935
Practice Address - Country:US
Practice Address - Phone:731-300-4800
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-04-01
Last Update Date:2017-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN4622225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist