Provider Demographics
NPI:1265192983
Name:JOHNSON, JORDIN R (NP)
Entity type:Individual
Prefix:
First Name:JORDIN
Middle Name:R
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3101 N CENTRAL AVE STE 550
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85012-2635
Mailing Address - Country:US
Mailing Address - Phone:602-230-7373
Mailing Address - Fax:
Practice Address - Street 1:2204 S DOBSON RD STE 102
Practice Address - Street 2:
Practice Address - City:MESA
Practice Address - State:AZ
Practice Address - Zip Code:85202-6457
Practice Address - Country:US
Practice Address - Phone:602-230-7373
Practice Address - Fax:480-628-8577
Is Sole Proprietor?:Yes
Enumeration Date:2021-12-21
Last Update Date:2024-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ268112363LP0808X
WAAP61439900363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health