Provider Demographics
NPI:1760736425
Name:JOHNSON, JENNIFER MICHELLE (PTA)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:MICHELLE
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:55 SPRINGHILL DR W
Mailing Address - Street 2:
Mailing Address - City:GREENBRIER
Mailing Address - State:AR
Mailing Address - Zip Code:72058-9237
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:333 1ST ST N STE 200
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE BEACH
Practice Address - State:FL
Practice Address - Zip Code:32250-6939
Practice Address - Country:US
Practice Address - Phone:904-241-8332
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-11-02
Last Update Date:2012-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR2381225200000X
TX2087240225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant