Provider Demographics
NPI:1245307826
Name:JOHNSON, JENNIFER L (CNM)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:L
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:CNM
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 5166
Mailing Address - Street 2:
Mailing Address - City:MERIDIAN
Mailing Address - State:MS
Mailing Address - Zip Code:39302-5166
Mailing Address - Country:US
Mailing Address - Phone:601-486-4210
Mailing Address - Fax:601-486-4219
Practice Address - Street 1:905C S FRONTAGE RD
Practice Address - Street 2:
Practice Address - City:MERIDIAN
Practice Address - State:MS
Practice Address - Zip Code:39301-6113
Practice Address - Country:US
Practice Address - Phone:601-486-4210
Practice Address - Fax:601-486-4219
Is Sole Proprietor?:No
Enumeration Date:2006-11-29
Last Update Date:2011-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYF001186367A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice Midwife
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01854282Medicaid
NY331951Medicare ID - Type Unspecified