Provider Demographics
NPI:1770505943
Name:JOHNSON, JENNIFER ARTEMIS (PA)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:ARTEMIS
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2101 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:JUNCTION
Mailing Address - State:TX
Mailing Address - Zip Code:76849-3024
Mailing Address - Country:US
Mailing Address - Phone:325-446-3305
Mailing Address - Fax:
Practice Address - Street 1:109 REID RD
Practice Address - Street 2:
Practice Address - City:JUNCTION
Practice Address - State:TX
Practice Address - Zip Code:76849-3008
Practice Address - Country:US
Practice Address - Phone:325-446-3305
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-24
Last Update Date:2010-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA03207363AM0700X, 363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX741622343OtherTAX ID#
TX741622343OtherTAX ID#