Healthcare Provider Details

I. General information

NPI: 1326693318
Provider Name (Legal Business Name): JENNIFER ELLEN JOHNSON
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/06/2019
Last Update Date: 05/01/2026
Certification Date: 05/01/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

26731 W POINT MACKENZIE RD
WASILLA AK
99623-8709
US

IV. Provider business mailing address

PO BOX 871545
WASILLA AK
99687-1545
US

V. Phone/Fax

Practice location:
  • Phone: 907-376-4534
  • Fax: 907-376-2348
Mailing address:
  • Phone: 907-376-4534
  • Fax: 907-376-2348

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number4420
License Number StateAK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: