Provider Demographics
NPI:1891277174
Name:JOHNSON, JENELLE KRISTINE
Entity Type:Individual
Prefix:
First Name:JENELLE
Middle Name:KRISTINE
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:HC 89 BOX 8190
Mailing Address - Street 2:
Mailing Address - City:TALKEETNA
Mailing Address - State:AK
Mailing Address - Zip Code:99676-9701
Mailing Address - Country:US
Mailing Address - Phone:907-733-2273
Mailing Address - Fax:907-733-1735
Practice Address - Street 1:34300 S TALKEETNA SPUR ROAD
Practice Address - Street 2:
Practice Address - City:TALKEETNA
Practice Address - State:AK
Practice Address - Zip Code:99676-9701
Practice Address - Country:US
Practice Address - Phone:907-733-2273
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-09-03
Last Update Date:2020-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK148759363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant