Provider Demographics
NPI:1740376862
Name:JOHNSON, JENNIFER ANN (PA)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:ANN
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:JENNIFER
Other - Middle Name:ANN
Other - Last Name:HINELINE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA
Mailing Address - Street 1:PO BOX 936857
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:31193-6857
Mailing Address - Country:US
Mailing Address - Phone:910-662-9500
Mailing Address - Fax:910-662-9501
Practice Address - Street 1:1500 PHYSICIANS DR
Practice Address - Street 2:
Practice Address - City:WILMINGTON
Practice Address - State:NC
Practice Address - Zip Code:28401-7356
Practice Address - Country:US
Practice Address - Phone:910-662-9500
Practice Address - Fax:910-662-9501
Is Sole Proprietor?:No
Enumeration Date:2006-10-05
Last Update Date:2022-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC103040363AM0700X, 363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC970025601OtherRAILROAD MEDICARE
NC2754675Medicare PIN
NC970025601OtherRAILROAD MEDICARE