Basic Information
| Provider Information | |||||||||
| NPI: | 1568651909 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | JOHNSON | ||||||||
| FirstName: | JENIFFER | ||||||||
| MiddleName: | SANTIAGO | ||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | N.P. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | SANTIAGO | ||||||||
| OtherFirstName: | JENIFFER | ||||||||
| OtherMiddleName: | HILLIADO | ||||||||
| OtherNamePrefix: | MS. | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | FNP | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 1182 N EUCLID ST | ||||||||
| Address2: | |||||||||
| City: | ANAHEIM | ||||||||
| State: | CA | ||||||||
| PostalCode: | 928011900 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7143999222 | ||||||||
| FaxNumber: | 7143999226 | ||||||||
| Practice Location | |||||||||
| Address1: | 1182 N EUCLID ST | ||||||||
| Address2: | |||||||||
| City: | ANAHEIM | ||||||||
| State: | CA | ||||||||
| PostalCode: | 928011900 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7143999222 | ||||||||
| FaxNumber: | 7143999226 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/22/2007 | ||||||||
| LastUpdateDate: | 03/06/2015 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
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| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | Y | ||||||||
| IsOrganizationSubpart: | |||||||||
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| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363L00000X | NP 17307 | CA | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
ID Information
| ID | Type | State | Issuer | Description | 581170 | 01 | CA | RN LICENSE | OTHER | 17307 | 01 | CA | NP LICENSE | OTHER |