Provider Demographics
NPI:1740922608
Name:JOHNSON, JILLIAN MARY (MSPAP, PA-C)
Entity type:Individual
Prefix:MS
First Name:JILLIAN
Middle Name:MARY
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:MSPAP, PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 13834
Mailing Address - Street 2:
Mailing Address - City:TALLAHASSEE
Mailing Address - State:FL
Mailing Address - Zip Code:32317-3834
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:425 W 19TH ST STE D&E
Practice Address - Street 2:
Practice Address - City:PANAMA CITY
Practice Address - State:FL
Practice Address - Zip Code:32405-4659
Practice Address - Country:US
Practice Address - Phone:850-818-0220
Practice Address - Fax:850-818-0156
Is Sole Proprietor?:No
Enumeration Date:2022-04-11
Last Update Date:2024-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL9115810363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant