Provider Demographics
NPI:1700076718
Name:JOHNSON, JEANNA M
Entity Type:Individual
Prefix:MS
First Name:JEANNA
Middle Name:M
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:922 GATES POND RD
Mailing Address - Street 2:PO BOX 991
Mailing Address - City:JACKSONVILLE
Mailing Address - State:VT
Mailing Address - Zip Code:05342-9607
Mailing Address - Country:US
Mailing Address - Phone:802-368-7116
Mailing Address - Fax:
Practice Address - Street 1:7540 N 19TH AVE
Practice Address - Street 2:SUITE200
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85021-7967
Practice Address - Country:US
Practice Address - Phone:888-873-4221
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-07-26
Last Update Date:2007-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT041-0000312225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant