Provider Demographics
NPI:1326193632
Name:JOHNSON, JAN M (BJ6359271)
Entity Type:Individual
Prefix:DR
First Name:JAN
Middle Name:M
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:BJ6359271
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:323 VIA PROMESA
Mailing Address - Street 2:
Mailing Address - City:SAN CLEMENTE
Mailing Address - State:CA
Mailing Address - Zip Code:92673-6820
Mailing Address - Country:US
Mailing Address - Phone:949-831-4472
Mailing Address - Fax:949-831-6499
Practice Address - Street 1:5 JOURNEY STE 140
Practice Address - Street 2:
Practice Address - City:ALISO VIEJO
Practice Address - State:CA
Practice Address - Zip Code:92656-5330
Practice Address - Country:US
Practice Address - Phone:949-831-4472
Practice Address - Fax:949-831-6499
Is Sole Proprietor?:No
Enumeration Date:2007-01-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXBJ63592712080A0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080A0000XAllopathic & Osteopathic PhysiciansPediatricsAdolescent Medicine