Provider Demographics
NPI:1336325620
Name:JOHNSTAD, JENNIFER ANNE (PA-C)
Entity Type:Individual
Prefix:MRS
First Name:JENNIFER
Middle Name:ANNE
Last Name:JOHNSTAD
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:JENNIFER
Other - Middle Name:ANNE
Other - Last Name:ROBERTS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:5717 PACIFIC CENTER BLVD STE 200
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92121-4250
Mailing Address - Country:US
Mailing Address - Phone:858-859-1188
Mailing Address - Fax:480-512-5486
Practice Address - Street 1:5717 PACIFIC CENTER BLVD STE 200
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92121-4250
Practice Address - Country:US
Practice Address - Phone:858-859-1188
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-01-16
Last Update Date:2019-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ2492363AS0400X
CAPA55545363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZP82782Medicare UPIN