Healthcare Provider Details

I. General information

NPI: 1205606084
Provider Name (Legal Business Name): JENNIFER L JOHNSON HAS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/03/2024
Last Update Date: 01/03/2024
Certification Date: 01/03/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

110 E MERRITT ISLAND CSWY
MERRITT ISLAND FL
32952-3674
US

IV. Provider business mailing address

3665 BRIAN CT
COCOA FL
32926-4436
US

V. Phone/Fax

Practice location:
  • Phone: 321-449-0033
  • Fax: 321-449-0033
Mailing address:
  • Phone: 321-501-0077
  • Fax: 321-449-0012

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code237700000X
TaxonomyHearing Instrument Specialist
License NumberAS5776
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: