Provider Demographics
NPI:1336190792
Name:JOHNSON, JENNIE SANTANGELO (PA-C)
Entity Type:Individual
Prefix:
First Name:JENNIE
Middle Name:SANTANGELO
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4800 BELFORT RD
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32256-6004
Mailing Address - Country:US
Mailing Address - Phone:904-389-7205
Mailing Address - Fax:904-265-4807
Practice Address - Street 1:1348 S 18TH ST STE 100
Practice Address - Street 2:
Practice Address - City:FERNANDINA BEACH
Practice Address - State:FL
Practice Address - Zip Code:32034-4785
Practice Address - Country:US
Practice Address - Phone:904-261-0878
Practice Address - Fax:904-277-7054
Is Sole Proprietor?:No
Enumeration Date:2006-05-12
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9103620363AM0700X, 363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA779795344AOtherGA MEDICAID
FLU7310YOtherMEDICARE
FL292466800Medicaid
FLU7310YOtherMEDICARE