Basic Information
| Provider Information | |||||||||
| NPI: | 1396763504 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | JOHNSON | ||||||||
| FirstName: | JENNIFER | ||||||||
| MiddleName: | M | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1035 ALTO ST | ||||||||
| Address2: | |||||||||
| City: | SANTA FE | ||||||||
| State: | NM | ||||||||
| PostalCode: | 875012406 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5059824425 | ||||||||
| FaxNumber: | 5059826280 | ||||||||
| Practice Location | |||||||||
| Address1: | 1035 ALTO STREET | ||||||||
| Address2: | |||||||||
| City: | SANTA FE | ||||||||
| State: | NM | ||||||||
| PostalCode: | 87501 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5059824425 | ||||||||
| FaxNumber: | 5059826280 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/17/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | 87-268 | NM | Y | Allopathic & Osteopathic Physicians | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | 00003202 | 05 | NM | MEDICAID |