Provider Demographics
NPI:1932381852
Name:JOHNSON, JENNIFER LYNN (PT)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:LYNN
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:825 N RAYMOND AVE
Mailing Address - Street 2:
Mailing Address - City:FULLERTON
Mailing Address - State:CA
Mailing Address - Zip Code:92831-3315
Mailing Address - Country:US
Mailing Address - Phone:714-871-0307
Mailing Address - Fax:
Practice Address - Street 1:20655 YORBA LINDA BLVD
Practice Address - Street 2:SUITE A
Practice Address - City:YORBA LINDA
Practice Address - State:CA
Practice Address - Zip Code:92886-7110
Practice Address - Country:US
Practice Address - Phone:714-693-0460
Practice Address - Fax:714-693-0444
Is Sole Proprietor?:No
Enumeration Date:2007-12-03
Last Update Date:2007-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT26799225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist