Provider Demographics
NPI:1689867145
Name:JOHNSON, JODY L (NP)
Entity Type:Individual
Prefix:
First Name:JODY
Middle Name:L
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:115 SPRING RIDGE DR
Mailing Address - Street 2:
Mailing Address - City:MURPHY
Mailing Address - State:TX
Mailing Address - Zip Code:75094-4267
Mailing Address - Country:US
Mailing Address - Phone:214-636-1198
Mailing Address - Fax:972-384-0694
Practice Address - Street 1:115 SPRING RIDGE DR
Practice Address - Street 2:
Practice Address - City:MURPHY
Practice Address - State:TX
Practice Address - Zip Code:75094-4267
Practice Address - Country:US
Practice Address - Phone:214-636-1198
Practice Address - Fax:972-384-0694
Is Sole Proprietor?:Yes
Enumeration Date:2007-08-19
Last Update Date:2011-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX531800363LG0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX1710172093OtherGROUP NPI NUMBER
TX00Y958OtherGROUP PROVIDER NUMBER