Provider Demographics
NPI:1679561096
Name:JOHNSON, JENNIFER MARIE-SMITH (PA-C)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:MARIE-SMITH
Last Name:JOHNSON
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 1:501 LAPEER AVE
Mailing Address - Street 2:HEALTH DELIVERY INC
Mailing Address - City:SAGINAW
Mailing Address - State:MI
Mailing Address - Zip Code:48607-1208
Mailing Address - Country:US
Mailing Address - Phone:989-759-6400
Mailing Address - Fax:989-759-6423
Practice Address - Street 1:804 S HAMILTON ST
Practice Address - Street 2:
Practice Address - City:SAGINAW
Practice Address - State:MI
Practice Address - Zip Code:48602-1516
Practice Address - Country:US
Practice Address - Phone:989-921-5372
Practice Address - Fax:989-921-5373
Is Sole Proprietor?:No
Enumeration Date:2005-10-10
Last Update Date:2021-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5601003542363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
1010145OtherMCLAREN HEALTH PLAN
139492OtherGREAT LAKES HEALTH PLAN
1010145OtherHEALTH ADVANTAGE PPO
MI256OtherCOMMUNITY CHOICE
MI2832651OtherMOLINA HEALTH CARE
970024194OtherRAILROAD MEDICARE
MI2832651OtherMOLINA HEALTH CARE
MI0G36111-077Medicare PIN