Provider Demographics
NPI:1417112343
Name:JOHNSON, JULIE JACKSON (PA-C)
Entity Type:Individual
Prefix:MRS
First Name:JULIE
Middle Name:JACKSON
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:175 S UNION BLVD
Mailing Address - Street 2:STE 350
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80910-3146
Mailing Address - Country:US
Mailing Address - Phone:719-590-7007
Mailing Address - Fax:719-590-7037
Practice Address - Street 1:2130 HOLLOW BROOK DR
Practice Address - Street 2:SUITE #100
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80918-8400
Practice Address - Country:US
Practice Address - Phone:719-590-7007
Practice Address - Fax:719-590-7037
Is Sole Proprietor?:No
Enumeration Date:2008-07-21
Last Update Date:2017-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO2615363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant