Provider Demographics
NPI:1437103702
Name:JOHNSON, JENNIFER ANN (PA)
Entity Type:Individual
Prefix:MS
First Name:JENNIFER
Middle Name:ANN
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4105 BRIARGATE PKWY
Mailing Address - Street 2:STE 300
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80920-3480
Mailing Address - Country:US
Mailing Address - Phone:719-776-7846
Mailing Address - Fax:719-776-3456
Practice Address - Street 1:4102 PINION DR
Practice Address - Street 2:
Practice Address - City:US AIR FORCE
Practice Address - State:CO
Practice Address - Zip Code:80840-2502
Practice Address - Country:US
Practice Address - Phone:719-333-5042
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-20
Last Update Date:2019-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1470-023363AS0400X
COPA.0004517363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI41960600Medicaid
WI41960600Medicaid
0012973601Medicare ID - Type Unspecified