Provider Demographics
NPI:1841567146
Name:JOHNSON, JENNIFER ANN (MOTR/L)
Entity Type:Individual
Prefix:MRS
First Name:JENNIFER
Middle Name:ANN
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:MOTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:155 ASHTON LN
Mailing Address - Street 2:
Mailing Address - City:CRYSTAL LAKE
Mailing Address - State:IL
Mailing Address - Zip Code:60014-6239
Mailing Address - Country:US
Mailing Address - Phone:574-274-5804
Mailing Address - Fax:
Practice Address - Street 1:2592 E GRAND AVE STE 209
Practice Address - Street 2:
Practice Address - City:LINDENHURST
Practice Address - State:IL
Practice Address - Zip Code:60046-5915
Practice Address - Country:US
Practice Address - Phone:847-265-1460
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-11-30
Last Update Date:2014-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL056007452225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist