Provider Demographics
NPI:1588856231
Name:JERRI L. JOHNSON, M.D., P.A.
Entity Type:Organization
Organization Name:JERRI L. JOHNSON, M.D., P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:AMY
Authorized Official - Middle Name:
Authorized Official - Last Name:KEENEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:407-260-2606
Mailing Address - Street 1:411 MAITLAND AVE
Mailing Address - Street 2:SUITE 1001
Mailing Address - City:ALTAMONTE SPRINGS
Mailing Address - State:FL
Mailing Address - Zip Code:32701-5448
Mailing Address - Country:US
Mailing Address - Phone:407-260-2606
Mailing Address - Fax:407-260-6339
Practice Address - Street 1:411 MAITLAND AVE
Practice Address - Street 2:SUITE 1001
Practice Address - City:ALTAMONTE SPRINGS
Practice Address - State:FL
Practice Address - Zip Code:32701-5448
Practice Address - Country:US
Practice Address - Phone:407-260-2606
Practice Address - Fax:407-260-6339
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-08-16
Last Update Date:2007-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME0049721174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL1588648265OtherNPI TYPE I
FL1588648265OtherNPI TYPE I
FL12752Medicare PIN