MEDICARE: JENNIFER MICHELLE JOHNSON PTA

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	225200000X	Physical Therapy Assistant	2381	AR
2	225200000X	Physical Therapy Assistant	2087240	TX

General Provider Information

NPI Number	:	1760736425
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JENNIFER MICHELLE JOHNSON PTA

Provider Business Mailing Address
First Line	:	55 SPRINGHILL DR W
Second Line	:
City	:	GREENBRIER
State	:	AR
Zip	:	72058-9237
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	333 1ST ST N STE 200
Second Line	:
City	:	JACKSONVILLE BEACH
State	:	FL
Zip	:	32250-6939
Country	:	US
Telephone Number	:	904-241-8332
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	11/02/2012
Last Update Date	:	11/02/2012

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Directions to “ JENNIFER MICHELLE JOHNSON PTA” Practice Location

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