Provider Demographics
NPI:1447245170
Name:JOHNSON, JEANNE RAE (CPHT)
Entity Type:Individual
Prefix:
First Name:JEANNE
Middle Name:RAE
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:CPHT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6255 HIGHLAND PARK DR
Mailing Address - Street 2:
Mailing Address - City:CHINCOTEAGUE
Mailing Address - State:VA
Mailing Address - Zip Code:23336-2215
Mailing Address - Country:US
Mailing Address - Phone:757-336-6279
Mailing Address - Fax:
Practice Address - Street 1:6300 MADDOX BLVD
Practice Address - Street 2:
Practice Address - City:CHINCOTEAGUE
Practice Address - State:VA
Practice Address - Zip Code:23336-2617
Practice Address - Country:US
Practice Address - Phone:757-336-3115
Practice Address - Fax:757-336-1947
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-09-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0230000643183700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183700000XPharmacy Service ProvidersPharmacy Technician