Provider Demographics
NPI:1205606084
Name:JOHNSON, JENNIFER L (HAS)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:L
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:HAS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3665 BRIAN CT
Mailing Address - Street 2:
Mailing Address - City:COCOA
Mailing Address - State:FL
Mailing Address - Zip Code:32926-4436
Mailing Address - Country:US
Mailing Address - Phone:321-501-0077
Mailing Address - Fax:321-449-0012
Practice Address - Street 1:110 E MERRITT ISLAND CSWY
Practice Address - Street 2:
Practice Address - City:MERRITT ISLAND
Practice Address - State:FL
Practice Address - Zip Code:32952-3674
Practice Address - Country:US
Practice Address - Phone:321-449-0033
Practice Address - Fax:321-449-0033
Is Sole Proprietor?:No
Enumeration Date:2024-01-03
Last Update Date:2024-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAS5776237700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes237700000XSpeech, Language and Hearing Service ProvidersHearing Instrument Specialist