Basic Information
| Provider Information | |||||||||
| NPI: | 1821209800 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | JOHNSON | ||||||||
| FirstName: | JENNIFER | ||||||||
| MiddleName: | BEDELL | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2500 NORTH STATE STREET | ||||||||
| Address2: | |||||||||
| City: | JACKSON | ||||||||
| State: | MS | ||||||||
| PostalCode: | 32916 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6019842538 | ||||||||
| FaxNumber: | 6018151854 | ||||||||
| Practice Location | |||||||||
| Address1: | 1000 MEDICAL CENTER BLVD | ||||||||
| Address2: | RADIOLOGY DEPARTMENT | ||||||||
| City: | LAWRENCEVILLE | ||||||||
| State: | GA | ||||||||
| PostalCode: | 300457694 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7709954321 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 05/24/2007 | ||||||||
| LastUpdateDate: | 03/11/2014 | ||||||||
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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 | 2085R0202X | 055604 | GA | N | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology | 2085R0202X | 14726 | MS | Y | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
ID Information
| ID | Type | State | Issuer | Description | P01194854 | 01 | MS | RAILROAD MEDICARE PTAN | OTHER |