Provider Demographics
NPI:1710103759
Name:JOHNSON, JO ANN G (DPH)
Entity Type:Individual
Prefix:DR
First Name:JO ANN
Middle Name:G
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:DPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:327 CECILIA DR
Mailing Address - Street 2:
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38117-1810
Mailing Address - Country:US
Mailing Address - Phone:901-767-3826
Mailing Address - Fax:901-524-1480
Practice Address - Street 1:865 POPLAR AVE
Practice Address - Street 2:
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38105-4608
Practice Address - Country:US
Practice Address - Phone:901-524-1336
Practice Address - Fax:901-524-1480
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN4993183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN4993OtherPHARMACIST TN LICENSE #