Healthcare Provider Details

I. General information

NPI: 1669708764
Provider Name (Legal Business Name): JENNA JOHNSON HS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: JENNA JOHNSON HS

II. Dates (important events)

Enumeration Date: 10/23/2009
Last Update Date: 10/23/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7155 MISSION GORGE RD
SAN DIEGO CA
92120-1130
US

IV. Provider business mailing address

7155 MISSION GORGE RD
SAN DIEGO CA
92120-1130
US

V. Phone/Fax

Practice location:
  • Phone: 858-300-0460
  • Fax: 858-300-0461
Mailing address:
  • Phone: 858-300-0460
  • Fax: 858-300-0461

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License NumberN/A
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: