Healthcare Provider Details

I. General information

NPI: 1558292813
Provider Name (Legal Business Name): JASMINE MARIE JOHNSON PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/26/2026
Last Update Date: 05/26/2026
Certification Date: 05/26/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

51 E MARKET ST
CLOVERDALE IN
46120-8427
US

IV. Provider business mailing address

14 MARYVALE CT
MOORESVILLE IN
46158-1227
US

V. Phone/Fax

Practice location:
  • Phone: 765-795-4242
  • Fax:
Mailing address:
  • Phone: 317-220-7973
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: