Provider Demographics
NPI:1568102317
Name:JOHNSON, JENNIFER ROSE (LMT)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:ROSE
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:JENNIFER
Other - Middle Name:ROSE
Other - Last Name:JOHNSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:361 NE FRANKLIN AVE BLDG C
Mailing Address - Street 2:
Mailing Address - City:BEND
Mailing Address - State:OR
Mailing Address - Zip Code:97701-4917
Mailing Address - Country:US
Mailing Address - Phone:541-323-3488
Mailing Address - Fax:541-323-3488
Practice Address - Street 1:361 NE FRANKLIN AVE BLDG C
Practice Address - Street 2:
Practice Address - City:BEND
Practice Address - State:OR
Practice Address - Zip Code:97701-4917
Practice Address - Country:US
Practice Address - Phone:541-323-3488
Practice Address - Fax:541-323-3488
Is Sole Proprietor?:No
Enumeration Date:2022-03-30
Last Update Date:2022-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR15011225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist