Provider Demographics
NPI:1558605717
Name:JOHNSON, JENIFER (OTR)
Entity Type:Individual
Prefix:
First Name:JENIFER
Middle Name:
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:OTR
Other - Prefix:
Other - First Name:JENIFER
Other - Middle Name:
Other - Last Name:FRITZ
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:6610 INTERSTATE 35 N
Mailing Address - Street 2:
Mailing Address - City:WACO
Mailing Address - State:TX
Mailing Address - Zip Code:76705-1136
Mailing Address - Country:US
Mailing Address - Phone:254-235-7604
Mailing Address - Fax:254-235-7612
Practice Address - Street 1:6610 INTERSTATE 35 N
Practice Address - Street 2:
Practice Address - City:WACO
Practice Address - State:TX
Practice Address - Zip Code:76705-1136
Practice Address - Country:US
Practice Address - Phone:254-235-7604
Practice Address - Fax:254-235-7612
Is Sole Proprietor?:Yes
Enumeration Date:2012-11-12
Last Update Date:2012-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX115118225XP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225XP0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX115118OtherOCCUPATIONAL THERAPY LIC #