Provider Demographics
NPI:1255337804
Name:JOHNSON, JEANETTE R (DPM)
Entity type:Individual
Prefix:DR
First Name:JEANETTE
Middle Name:R
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6 REGIONAL CR
Mailing Address - Street 2:SUITE A
Mailing Address - City:PINEHURST
Mailing Address - State:NC
Mailing Address - Zip Code:28374
Mailing Address - Country:US
Mailing Address - Phone:910-295-9255
Mailing Address - Fax:
Practice Address - Street 1:6 REGIONAL CR
Practice Address - Street 2:SUITE A
Practice Address - City:PINEHURST
Practice Address - State:NC
Practice Address - Zip Code:28374
Practice Address - Country:US
Practice Address - Phone:910-295-9255
Practice Address - Fax:910-295-7255
Is Sole Proprietor?:No
Enumeration Date:2005-06-27
Last Update Date:2011-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC531213EP1101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213EP1101XPodiatric Medicine & Surgery Service ProvidersPodiatristPrimary Podiatric Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL65554OtherBLUE CROSS/BLUE SHIELD
FLU68700Medicare UPIN