Provider Demographics
NPI:1710006382
Name:JOHNSON, JENNIFER MYIA (MD)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:MYIA
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1628
Mailing Address - Street 2:
Mailing Address - City:LONGMONT
Mailing Address - State:CO
Mailing Address - Zip Code:80502-1628
Mailing Address - Country:US
Mailing Address - Phone:303-651-5139
Mailing Address - Fax:
Practice Address - Street 1:2880 FOLSOM ST STE 100
Practice Address - Street 2:
Practice Address - City:BOULDER
Practice Address - State:CO
Practice Address - Zip Code:80304-3769
Practice Address - Country:US
Practice Address - Phone:303-327-7047
Practice Address - Fax:303-443-7168
Is Sole Proprietor?:No
Enumeration Date:2007-03-28
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO43964207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO56929340Medicaid
CO56929340Medicaid
CO56929340Medicaid