Healthcare Provider Details

I. General information

NPI: 1245307826
Provider Name (Legal Business Name): JENNIFER L JOHNSON CNM
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/29/2006
Last Update Date: 10/31/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

905C S FRONTAGE RD
MERIDIAN MS
39301-6113
US

IV. Provider business mailing address

PO BOX 5166
MERIDIAN MS
39302-5166
US

V. Phone/Fax

Practice location:
  • Phone: 601-486-4210
  • Fax: 601-486-4219
Mailing address:
  • Phone: 601-486-4210
  • Fax: 601-486-4219

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367A00000X
TaxonomyAdvanced Practice Midwife
License NumberF001186
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: