Provider Demographics
NPI:1568787018
Name:JOHNSON, JENNIFER LYNN (MSCCC-SLP)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:LYNN
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:MSCCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:376 PASCOE BLVD
Mailing Address - Street 2:APT 22
Mailing Address - City:BOWLING GREEN
Mailing Address - State:KY
Mailing Address - Zip Code:42104-5455
Mailing Address - Country:US
Mailing Address - Phone:270-535-2639
Mailing Address - Fax:
Practice Address - Street 1:376 PASCOE BLVD
Practice Address - Street 2:APT 22
Practice Address - City:BOWLING GREEN
Practice Address - State:KY
Practice Address - Zip Code:42104-5455
Practice Address - Country:US
Practice Address - Phone:270-535-2639
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-03-27
Last Update Date:2010-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYKY3383235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist