Provider Demographics
NPI:1407074750
Name:JOHANSEN, JENNIFER L (RPH, PHARMD, BCPS)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:L
Last Name:JOHANSEN
Suffix:
Gender:F
Credentials:RPH, PHARMD, BCPS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5 CRESCENT DR
Mailing Address - Street 2:NY0200
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19112-1001
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:5 CRESCENT DR
Practice Address - Street 2:NY0200
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19112-1001
Practice Address - Country:US
Practice Address - Phone:215-751-5222
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-04-23
Last Update Date:2014-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PARP044501L183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist