Provider Demographics
NPI:1801266150
Name:JOHNSON, JENNIFER GAIL (PTA)
Entity type:Individual
Prefix:MRS
First Name:JENNIFER
Middle Name:GAIL
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6105 OLD NEWTON RD
Mailing Address - Street 2:
Mailing Address - City:CAMILLA
Mailing Address - State:GA
Mailing Address - Zip Code:31730-5404
Mailing Address - Country:US
Mailing Address - Phone:229-403-7994
Mailing Address - Fax:229-336-1151
Practice Address - Street 1:130 E BROAD ST
Practice Address - Street 2:
Practice Address - City:CAMILLA
Practice Address - State:GA
Practice Address - Zip Code:31730-1809
Practice Address - Country:US
Practice Address - Phone:229-336-1115
Practice Address - Fax:229-336-1151
Is Sole Proprietor?:No
Enumeration Date:2015-09-30
Last Update Date:2015-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPTA002442225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAPTA002442OtherSTATE OF GEORGIA