Provider Demographics
NPI:1437670858
Name:JOHNSON, JANE
Entity Type:Individual
Prefix:
First Name:JANE
Middle Name:
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:722 PLUM LN
Mailing Address - Street 2:
Mailing Address - City:CLARKESVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30523-1446
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:865 AUSTIN DR
Practice Address - Street 2:
Practice Address - City:DEMOREST
Practice Address - State:GA
Practice Address - Zip Code:30535-4513
Practice Address - Country:US
Practice Address - Phone:706-754-8811
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-07-06
Last Update Date:2017-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN142265363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily