Healthcare Provider Details

I. General information

NPI: 1982648192
Provider Name (Legal Business Name): JENNIFER JOHNSON M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/16/2006
Last Update Date: 03/07/2023
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

366 SAN MIGUEL DR SUITE 209
NEWPORT BEACH CA
92660-7817
US

IV. Provider business mailing address

PO BOX 9996
NEWPORT BEACH CA
92658-1996
US

V. Phone/Fax

Practice location:
  • Phone: 949-856-2701
  • Fax: 949-625-7516
Mailing address:
  • Phone: 949-856-2701
  • Fax: 949-625-7516

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberA40753
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code2080A0000X
TaxonomyPediatric Adolescent Medicine Physician
License NumberA40753
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: