Provider Demographics
NPI:1982648192
Name:JOHNSON, JENNIFER (MD)
Entity Type:Individual
Prefix:DR
First Name:JENNIFER
Middle Name:
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 9996
Mailing Address - Street 2:
Mailing Address - City:NEWPORT BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:92658-1996
Mailing Address - Country:US
Mailing Address - Phone:949-856-2701
Mailing Address - Fax:949-625-7516
Practice Address - Street 1:366 SAN MIGUEL DR
Practice Address - Street 2:SUITE 209
Practice Address - City:NEWPORT BEACH
Practice Address - State:CA
Practice Address - Zip Code:92660-7817
Practice Address - Country:US
Practice Address - Phone:949-856-2701
Practice Address - Fax:949-625-7516
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-16
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA40753208000000X, 2080A0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080A0000XAllopathic & Osteopathic PhysiciansPediatricsAdolescent Medicine
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAA40753OtherMEDICAL LICENSE
AJ2725337OtherDEA
AJ2725337OtherDEA