Provider Demographics
NPI:1558037598
Name:JOHNSON, JENNIFER ROSE (CCC-SLP)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:ROSE
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:CCC-SLP
Other - Prefix:
Other - First Name:JENNIFER
Other - Middle Name:ROSE
Other - Last Name:KLEINKE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:CCC-SLP
Mailing Address - Street 1:3895 CAMPERDOWN DR
Mailing Address - Street 2:
Mailing Address - City:LANSING
Mailing Address - State:MI
Mailing Address - Zip Code:48911-6161
Mailing Address - Country:US
Mailing Address - Phone:734-788-5922
Mailing Address - Fax:
Practice Address - Street 1:1026 RED CEDAR RD
Practice Address - Street 2:
Practice Address - City:EAST LANSING
Practice Address - State:MI
Practice Address - Zip Code:48824-3405
Practice Address - Country:US
Practice Address - Phone:517-884-8869
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-08-19
Last Update Date:2021-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI7101006983235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist