Provider Demographics
NPI:1457311177
Name:JOHNSON, JODIE (NP)
Entity Type:Individual
Prefix:
First Name:JODIE
Middle Name:
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 15386
Mailing Address - Street 2:
Mailing Address - City:DURHAM
Mailing Address - State:NC
Mailing Address - Zip Code:27704-0386
Mailing Address - Country:US
Mailing Address - Phone:919-477-5152
Mailing Address - Fax:919-477-5474
Practice Address - Street 1:3643 N ROXBORO ST
Practice Address - Street 2:
Practice Address - City:DURHAM
Practice Address - State:NC
Practice Address - Zip Code:27704-2702
Practice Address - Country:US
Practice Address - Phone:919-477-5152
Practice Address - Fax:919-477-5474
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-25
Last Update Date:2007-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC201338363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC2599237Medicare PIN
NCP09272Medicare UPIN