Provider Demographics
NPI:1205683869
Name:JOHNSON, JENNIFER MARIE (FNP-C)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:MARIE
Last Name:JOHNSON
Suffix:
Gender:
Credentials:FNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1675 STEWART ST
Mailing Address - Street 2:
Mailing Address - City:WELCH
Mailing Address - State:WV
Mailing Address - Zip Code:24801-2142
Mailing Address - Country:US
Mailing Address - Phone:304-888-0514
Mailing Address - Fax:
Practice Address - Street 1:PO BOX 507
Practice Address - Street 2:
Practice Address - City:GARY
Practice Address - State:WV
Practice Address - Zip Code:24836-0507
Practice Address - Country:US
Practice Address - Phone:304-448-2101
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-05-02
Last Update Date:2025-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV97296163W00000X
WV119260363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163W00000XNursing Service ProvidersRegistered Nurse