Provider Demographics
NPI:1013563634
Name:JOHNSON, JEAN NICOLE
Entity Type:Individual
Prefix:
First Name:JEAN NICOLE
Middle Name:
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 1:245 ORIOLE MILLS RD
Mailing Address - Street 2:
Mailing Address - City:RHINEBECK
Mailing Address - State:NY
Mailing Address - Zip Code:12572-3417
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:245 ORIOLE MILLS RD
Practice Address - Street 2:
Practice Address - City:RHINEBECK
Practice Address - State:NY
Practice Address - Zip Code:12572-3417
Practice Address - Country:US
Practice Address - Phone:845-505-3082
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-08-11
Last Update Date:2019-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist