Provider Demographics
NPI:1760588388
Name:JOHNSON, JENNIFER L (PA-C)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:L
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:PO BOX 1209
Mailing Address - Street 2:
Mailing Address - City:MURRELLS INLET
Mailing Address - State:SC
Mailing Address - Zip Code:29576-1209
Mailing Address - Country:US
Mailing Address - Phone:843-652-8220
Mailing Address - Fax:843-527-7080
Practice Address - Street 1:9699 OCEAN HWY
Practice Address - Street 2:
Practice Address - City:PAWLEYS ISLAND
Practice Address - State:SC
Practice Address - Zip Code:29585-7425
Practice Address - Country:US
Practice Address - Phone:843-237-4296
Practice Address - Fax:843-237-0495
Is Sole Proprietor?:No
Enumeration Date:2006-09-15
Last Update Date:2015-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SCA1133363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCA1133OtherSTATE MEDICAL LICENSE