Provider Demographics
NPI:1457401747
Name:JOHNSON, JENNIFER L (OD)
Entity Type:Individual
Prefix:DR
First Name:JENNIFER
Middle Name:L
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 1:124 E BANDERA RD
Mailing Address - Street 2:STE 403
Mailing Address - City:BOERNE
Mailing Address - State:TX
Mailing Address - Zip Code:78006-2849
Mailing Address - Country:US
Mailing Address - Phone:830-331-8745
Mailing Address - Fax:866-897-9855
Practice Address - Street 1:124 E BANDERA RD
Practice Address - Street 2:STE 403
Practice Address - City:BOERNE
Practice Address - State:TX
Practice Address - Zip Code:78006-2849
Practice Address - Country:US
Practice Address - Phone:830-331-8745
Practice Address - Fax:866-897-9855
Is Sole Proprietor?:No
Enumeration Date:2007-01-11
Last Update Date:2011-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX5869TG152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX168232001Medicaid
TX8L18438Medicare PIN
TX168232001Medicaid