Healthcare Provider Details

I. General information

NPI: 1710969191
Provider Name (Legal Business Name): JENNA GABRIELLE JOHNSON PSY D
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/19/2005
Last Update Date: 12/04/2023
Certification Date: 12/04/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

230 S SHEPHERD ST STE D
SONORA CA
95370-5076
US

IV. Provider business mailing address

230 S SHEPHERD ST STE D
SONORA CA
95370-5076
US

V. Phone/Fax

Practice location:
  • Phone: 209-432-3616
  • Fax:
Mailing address:
  • Phone: 209-432-3616
  • Fax: 209-694-4571

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License NumberPSY18496
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: