Provider Demographics
NPI:1629199989
Name:JOHNSON, JENNIFER LYN (DC)
Entity Type:Individual
Prefix:DR
First Name:JENNIFER
Middle Name:LYN
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:90 MAINE AVE
Mailing Address - Street 2:
Mailing Address - City:GARDINER
Mailing Address - State:ME
Mailing Address - Zip Code:04345-2131
Mailing Address - Country:US
Mailing Address - Phone:207-582-2222
Mailing Address - Fax:207-588-0891
Practice Address - Street 1:90 MAINE AVE
Practice Address - Street 2:
Practice Address - City:GARDINER
Practice Address - State:ME
Practice Address - Zip Code:04345-2131
Practice Address - Country:US
Practice Address - Phone:207-582-2222
Practice Address - Fax:207-588-0891
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-03
Last Update Date:2011-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MECR1261111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME00002167772OtherUNITED HEALTH CARE
ME00002167772OtherUNITED HEALTH CARE
MEU85328Medicare UPIN