Healthcare Provider Details

I. General information

NPI: 1942758859
Provider Name (Legal Business Name): JENNIFER JOHANSEN APN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/20/2016
Last Update Date: 05/08/2021
Certification Date: 05/08/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3350 ROUTE 138 STE 126
WALL TOWNSHIP NJ
07719-9694
US

IV. Provider business mailing address

3600 ROUTE 66 FL 3
NEPTUNE NJ
07753-2645
US

V. Phone/Fax

Practice location:
  • Phone: 732-280-6455
  • Fax:
Mailing address:
  • Phone: 732-807-0877
  • Fax: 201-751-1680

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number26NJ00668000
License Number StateNJ
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number26NJ00668000
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: