Provider Demographics
NPI:1417221755
Name:JOHNSON, JENNIFER A (DNP, APRN, ACNS-BC)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:A
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:DNP, APRN, ACNS-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1000 W CANNON ST
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76104-3029
Mailing Address - Country:US
Mailing Address - Phone:817-725-7900
Mailing Address - Fax:817-335-4418
Practice Address - Street 1:1001 PENNSYLVANIA AVE
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76104-2228
Practice Address - Country:US
Practice Address - Phone:817-877-5858
Practice Address - Fax:817-335-4418
Is Sole Proprietor?:No
Enumeration Date:2012-03-05
Last Update Date:2017-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX601283364S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes364S00000XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse Specialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX359670201Medicaid
TX279213YSE6Medicare PIN