Healthcare Provider Details

I. General information

NPI: 1891784245
Provider Name (Legal Business Name): ELIZABETH JO JOHNSON M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/18/2005
Last Update Date: 11/21/2024
Certification Date: 11/21/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

215 W YAKIMA STE 3
JEROME ID
83338-6164
US

IV. Provider business mailing address

215 W YAKIMA STE 3
JEROME ID
83338-6164
US

V. Phone/Fax

Practice location:
  • Phone: 208-734-1394
  • Fax: 208-329-5040
Mailing address:
  • Phone: 208-734-1394
  • Fax: 208-329-5040

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberM-9318
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: