Provider Demographics
NPI:1851599187
Name:JOHNSON, JENNIFER MICHELLE (MPH, RD)
Entity Type:Individual
Prefix:MRS
First Name:JENNIFER
Middle Name:MICHELLE
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:MPH, RD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1555 MESA VERDE DR E
Mailing Address - Street 2:#17L
Mailing Address - City:COSTA MESA
Mailing Address - State:CA
Mailing Address - Zip Code:92626-5120
Mailing Address - Country:US
Mailing Address - Phone:949-452-1750
Mailing Address - Fax:
Practice Address - Street 1:1555 MESA VERDE DR E
Practice Address - Street 2:#17L
Practice Address - City:COSTA MESA
Practice Address - State:CA
Practice Address - Zip Code:92626-5120
Practice Address - Country:US
Practice Address - Phone:949-452-1750
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-07-09
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA927649133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered