Provider Demographics
NPI:1982102083
Name:JOHNSON, JONATHAN FRANKLIN JR (FNP)
Entity Type:Individual
Prefix:
First Name:JONATHAN
Middle Name:FRANKLIN
Last Name:JOHNSON
Suffix:JR
Gender:M
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:400 COLUMBUS AVENUE
Mailing Address - Street 2:CREDENTIALING SPECIALIST
Mailing Address - City:NEW HAVEN
Mailing Address - State:CT
Mailing Address - Zip Code:06519-2613
Mailing Address - Country:US
Mailing Address - Phone:203-503-3000
Mailing Address - Fax:203-503-6515
Practice Address - Street 1:428 COLUMBUS AVENUE
Practice Address - Street 2:PEDIATRICS
Practice Address - City:NEW HAVEN
Practice Address - State:CT
Practice Address - Zip Code:06519-1233
Practice Address - Country:US
Practice Address - Phone:203-503-3030
Practice Address - Fax:203-503-3599
Is Sole Proprietor?:No
Enumeration Date:2018-01-24
Last Update Date:2019-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT119709163W00000X
AL1-167832363LF0000X
CT8521363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT004235900Medicaid