Provider Demographics
NPI:1831866300
Name:JOHNSON, JENNIFER EVETTE
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:EVETTE
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 1:605 S 1ST ST
Mailing Address - Street 2:
Mailing Address - City:MADILL
Mailing Address - State:OK
Mailing Address - Zip Code:73446-3807
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:605 S 1ST ST
Practice Address - Street 2:
Practice Address - City:MADILL
Practice Address - State:OK
Practice Address - Zip Code:73446-3807
Practice Address - Country:US
Practice Address - Phone:580-795-3794
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-08-24
Last Update Date:2021-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
No175T00000XOther Service ProvidersPeer Specialist