Provider Demographics
NPI:1225288376
Name:JOHNSON, JENNIFER HOLT (PA-C)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:HOLT
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:JENNIFER
Other - Middle Name:ASHLEY
Other - Last Name:HOLT
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:PA-C
Mailing Address - Street 1:74 E 11800 S STE 360
Mailing Address - Street 2:
Mailing Address - City:DRAPER
Mailing Address - State:UT
Mailing Address - Zip Code:84020-5006
Mailing Address - Country:US
Mailing Address - Phone:801-260-3687
Mailing Address - Fax:801-260-3688
Practice Address - Street 1:74 E 11800 S STE 360
Practice Address - Street 2:
Practice Address - City:DRAPER
Practice Address - State:UT
Practice Address - Zip Code:84020-5006
Practice Address - Country:US
Practice Address - Phone:801-260-3687
Practice Address - Fax:801-260-3688
Is Sole Proprietor?:No
Enumeration Date:2008-09-25
Last Update Date:2015-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT7114800-8906363A00000X
UT7114800-1206363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant