Provider Demographics
NPI:1437174877
Name:JOHNSON, JENNIFER NICOLE (PT)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:NICOLE
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:JENNIFER
Other - Middle Name:NICOLE
Other - Last Name:PULLIAM
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DPT, OCS, FAAOMPT
Mailing Address - Street 1:271 FT RICHARDSON
Mailing Address - Street 2:
Mailing Address - City:GOODFELLOW AFB
Mailing Address - State:TX
Mailing Address - Zip Code:76908
Mailing Address - Country:US
Mailing Address - Phone:719-510-1580
Mailing Address - Fax:
Practice Address - Street 1:271 FT RICHARDSON AVE
Practice Address - Street 2:
Practice Address - City:GOODFELLOW AFB
Practice Address - State:TX
Practice Address - Zip Code:76908
Practice Address - Country:US
Practice Address - Phone:325-654-5190
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-13
Last Update Date:2022-11-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM3088171000000X
CA35821171000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171000000XOther Service ProvidersMilitary Health Care Provider