Provider Demographics
NPI:1336452655
Name:JOHNSON, JENNIFER LYNN (OD)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:LYNN
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:70 E 68TH PL
Mailing Address - Street 2:
Mailing Address - City:MERRILLVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:46410-3506
Mailing Address - Country:US
Mailing Address - Phone:219-736-2020
Mailing Address - Fax:219-769-3884
Practice Address - Street 1:117 DEANNA DR
Practice Address - Street 2:
Practice Address - City:LOWELL
Practice Address - State:IN
Practice Address - Zip Code:46356
Practice Address - Country:US
Practice Address - Phone:219-696-8077
Practice Address - Fax:219-696-3570
Is Sole Proprietor?:No
Enumeration Date:2010-07-15
Last Update Date:2018-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN18003889A152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist