Healthcare Provider Details

I. General information

NPI: 1629674627
Provider Name (Legal Business Name): JENIFER MICHELLE JOHNSON
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/07/2020
Last Update Date: 02/21/2025
Certification Date: 02/21/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

405 W 5TH ST
SANTA ANA CA
92701-4599
US

IV. Provider business mailing address

405 W 5TH ST
SANTA ANA CA
92701-4599
US

V. Phone/Fax

Practice location:
  • Phone: 714-935-6363
  • Fax: 714-935-8112
Mailing address:
  • Phone: 714-935-6344
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code175T00000X
TaxonomyPeer Specialist
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code225400000X
TaxonomyRehabilitation Practitioner
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code172V00000X
TaxonomyCommunity Health Worker
License Number
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: