Provider Demographics
NPI:1710969191
Name:JOHNSON, JENNA GABRIELLE (PSY D)
Entity Type:Individual
Prefix:
First Name:JENNA
Middle Name:GABRIELLE
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:PSY D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:230 S SHEPHERD ST STE D
Mailing Address - Street 2:
Mailing Address - City:SONORA
Mailing Address - State:CA
Mailing Address - Zip Code:95370-5076
Mailing Address - Country:US
Mailing Address - Phone:209-432-3616
Mailing Address - Fax:209-694-4571
Practice Address - Street 1:230 S SHEPHERD ST STE D
Practice Address - Street 2:
Practice Address - City:SONORA
Practice Address - State:CA
Practice Address - Zip Code:95370-5076
Practice Address - Country:US
Practice Address - Phone:209-432-3616
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-11-19
Last Update Date:2023-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY18496103TC0700X, 103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA0PL184961Medicare PIN