Provider Demographics
NPI:1316182926
Name:JENNIFER JOHNSTAD LLC
Entity Type:Organization
Organization Name:JENNIFER JOHNSTAD LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN ASSISTANT
Authorized Official - Prefix:MRS
Authorized Official - First Name:JENNIFER
Authorized Official - Middle Name:ANNE
Authorized Official - Last Name:JOHNSTAD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:480-512-3970
Mailing Address - Street 1:2421 E SOUTHERN AVE
Mailing Address - Street 2:SUITE 1
Mailing Address - City:TEMPE
Mailing Address - State:AZ
Mailing Address - Zip Code:85282-7612
Mailing Address - Country:US
Mailing Address - Phone:480-485-2158
Mailing Address - Fax:480-839-4727
Practice Address - Street 1:2421 E SOUTHERN AVE
Practice Address - Street 2:SUITE 1
Practice Address - City:TEMPE
Practice Address - State:AZ
Practice Address - Zip Code:85282-7612
Practice Address - Country:US
Practice Address - Phone:480-485-2158
Practice Address - Fax:480-839-4727
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-12-10
Last Update Date:2009-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ2492363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgicalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZP82782Medicare UPIN