Provider Demographics
NPI:1891772521
Name:JENNINGS JOHNSON, LAUREL J (MD)
Entity Type:Individual
Prefix:DR
First Name:LAUREL
Middle Name:J
Last Name:JENNINGS JOHNSON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:DR
Other - First Name:LAUREL
Other - Middle Name:J
Other - Last Name:JENNINGS
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:323 SW 10TH ST
Mailing Address - Street 2:
Mailing Address - City:MADISON
Mailing Address - State:SD
Mailing Address - Zip Code:57042-3200
Mailing Address - Country:US
Mailing Address - Phone:605-256-6951
Mailing Address - Fax:605-256-6953
Practice Address - Street 1:323 SW 10TH ST
Practice Address - Street 2:
Practice Address - City:MADISON
Practice Address - State:SD
Practice Address - Zip Code:57042-3200
Practice Address - Country:US
Practice Address - Phone:605-256-6951
Practice Address - Fax:605-256-6953
Is Sole Proprietor?:No
Enumeration Date:2005-12-23
Last Update Date:2016-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SD5501207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
SD5611710Medicaid
SD5611710Medicaid
SDI00585Medicare UPIN