Healthcare Provider Details

I. General information

NPI: 1518309806
Provider Name (Legal Business Name): MRS. JENNIFER LEIGH JOHNSON
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/26/2013
Last Update Date: 01/29/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2829 4TH AVE STE 150
LAKE CHARLES LA
70601-7897
US

IV. Provider business mailing address

7605 CHRIS LN
LAKE CHARLES LA
70607-0747
US

V. Phone/Fax

Practice location:
  • Phone: 337-477-7091
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code222Q00000X
TaxonomyDevelopmental Therapist
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: