Provider Demographics
NPI:1770746687
Name:JOHNSON, JENNIFER JUDITH (COTA/L)
Entity type:Individual
Prefix:MISS
First Name:JENNIFER
Middle Name:JUDITH
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:COTA/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15 PINEWOODS RD
Mailing Address - Street 2:
Mailing Address - City:LISBON
Mailing Address - State:ME
Mailing Address - Zip Code:04250-6249
Mailing Address - Country:US
Mailing Address - Phone:207-408-6916
Mailing Address - Fax:
Practice Address - Street 1:51 WINSHIP ST
Practice Address - Street 2:
Practice Address - City:BATH
Practice Address - State:ME
Practice Address - Zip Code:04530-2843
Practice Address - Country:US
Practice Address - Phone:207-443-9772
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-07-10
Last Update Date:2008-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEOA2184224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant