Healthcare Provider Details

I. General information

NPI: 1710360094
Provider Name (Legal Business Name): JENNIFER JOHNSON, M.D., A PROFESSIONAL CORPORATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/03/2015
Last Update Date: 07/03/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

366 SAN MIGUEL DR STE 209
NEWPORT BEACH CA
92660-7810
US

IV. Provider business mailing address

366 SAN MIGUEL DR STE 209
NEWPORT BEACH CA
92660-7810
US

V. Phone/Fax

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

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2080A0000X
TaxonomyPediatric Adolescent Medicine Physician
License NumberA40753
License Number StateCA

VIII. Authorized Official

Name: JENNIFER JOHNSON
Title or Position: CEO
Credential: M.D.
Phone: 949-856-2701