Healthcare Provider Details

I. General information

NPI: 1790020667
Provider Name (Legal Business Name): JENIFER RENE JOHNSON
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/04/2012
Last Update Date: 02/22/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1705 17TH AVE
VERO BEACH FL
32960-3641
US

IV. Provider business mailing address

1524 PAR CT
VERO BEACH FL
32966-2505
US

V. Phone/Fax

Practice location:
  • Phone: 772-562-6877
  • Fax:
Mailing address:
  • Phone: 772-486-1299
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License NumberPTA23396
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: