Provider Demographics
NPI:1992023378
Name:JOHNSON, JENNIFER L (RN)
Entity Type:Individual
Prefix:MS
First Name:JENNIFER
Middle Name:L
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:993 DRY CREEK RD
Mailing Address - Street 2:
Mailing Address - City:CANTON
Mailing Address - State:MS
Mailing Address - Zip Code:39046-8686
Mailing Address - Country:US
Mailing Address - Phone:601-573-7582
Mailing Address - Fax:
Practice Address - Street 1:993 DRY CREEK RD
Practice Address - Street 2:
Practice Address - City:CANTON
Practice Address - State:MS
Practice Address - Zip Code:39046-8686
Practice Address - Country:US
Practice Address - Phone:601-573-7582
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-05-11
Last Update Date:2019-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS906486163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse