Provider Demographics
NPI:1336549013
Name:JOHNSON, JENNIFER (COTA)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:COTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:413 E WASHINGTON ST
Mailing Address - Street 2:
Mailing Address - City:MONTPELIER
Mailing Address - State:OH
Mailing Address - Zip Code:43543-1575
Mailing Address - Country:US
Mailing Address - Phone:419-551-1189
Mailing Address - Fax:
Practice Address - Street 1:1104 WESLEY AVE
Practice Address - Street 2:
Practice Address - City:BRYAN
Practice Address - State:OH
Practice Address - Zip Code:43506-2579
Practice Address - Country:US
Practice Address - Phone:419-636-5071
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-08-29
Last Update Date:2014-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHOTA-05816320700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320700000XResidential Treatment FacilitiesResidential Treatment Facility, Physical Disabilities