Healthcare Provider Details

I. General information

NPI: 1699363481
Provider Name (Legal Business Name): MRS. JENNIFER L JOHNSON
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/06/2021
Last Update Date: 06/30/2026
Certification Date: 06/30/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

209 FLAGSTONE LN
RAEFORD NC
28376-3260
US

IV. Provider business mailing address

385 N PECAN ST
PINEBLUFF NC
28373-8287
US

V. Phone/Fax

Practice location:
  • Phone: 207-479-4243
  • Fax:
Mailing address:
  • Phone: 207-479-4243
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: