Basic Information
| Provider Information | |||||||||
| NPI: | 1437103702 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | JOHNSON | ||||||||
| FirstName: | JENNIFER | ||||||||
| MiddleName: | ANN | ||||||||
| NamePrefix: | MS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | PA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4105 BRIARGATE PKWY | ||||||||
| Address2: | STE 300 | ||||||||
| City: | COLORADO SPRINGS | ||||||||
| State: | CO | ||||||||
| PostalCode: | 809203480 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7197767846 | ||||||||
| FaxNumber: | 7197763456 | ||||||||
| Practice Location | |||||||||
| Address1: | 4102 PINION DR | ||||||||
| Address2: | |||||||||
| City: | US AIR FORCE | ||||||||
| State: | CO | ||||||||
| PostalCode: | 808402502 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7193335042 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 05/20/2006 | ||||||||
| LastUpdateDate: | 12/19/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 12/19/2019 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363AS0400X | 1470-023 | WI | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Surgical | 363AS0400X | PA.0004517 | CO | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Surgical |
ID Information
| ID | Type | State | Issuer | Description | 41960600 | 05 | WI | MEDICAID |