Provider Demographics
NPI:1841974524
Name:JOHNSON, JENNA NICOLE (DDS)
Entity type:Individual
Prefix:
First Name:JENNA
Middle Name:NICOLE
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3201 DEL PRADO BLVD S STE 120
Mailing Address - Street 2:
Mailing Address - City:CAPE CORAL
Mailing Address - State:FL
Mailing Address - Zip Code:33904-7206
Mailing Address - Country:US
Mailing Address - Phone:239-542-5335
Mailing Address - Fax:
Practice Address - Street 1:3201 DEL PRADO BLVD S STE 120
Practice Address - Street 2:
Practice Address - City:CAPE CORAL
Practice Address - State:FL
Practice Address - Zip Code:33904-7206
Practice Address - Country:US
Practice Address - Phone:239-542-5335
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-06-13
Last Update Date:2025-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL28113122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist