Provider Demographics
NPI:1578816856
Name:JOHANSSON, JENNIFER (PA-C)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:
Last Name:JOHANSSON
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:235 GREENFIELD PKWY
Mailing Address - Street 2:
Mailing Address - City:LIVERPOOL
Mailing Address - State:NY
Mailing Address - Zip Code:13088-6651
Mailing Address - Country:US
Mailing Address - Phone:315-452-3376
Mailing Address - Fax:518-479-3794
Practice Address - Street 1:235 GREENFIELD PKWY
Practice Address - Street 2:
Practice Address - City:LIVERPOOL
Practice Address - State:NY
Practice Address - Zip Code:13088-6651
Practice Address - Country:US
Practice Address - Phone:315-452-3376
Practice Address - Fax:518-479-3794
Is Sole Proprietor?:No
Enumeration Date:2012-10-23
Last Update Date:2021-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY016039207N00000X, 363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYW34181OtherMEDICARE PTAN
NYAA0422OtherMEDICARE PTAN
NYBA0876OtherMEDICARE PTAN
NYW34181OtherMEDICARE PTAN
NYJ400118043Medicare PIN
NYAA0422OtherMEDICARE PTAN
NYJ400118030Medicare PIN
NYBA0876OtherMEDICARE PTAN
NYJ400092700Medicare PIN