Healthcare Provider Details

I. General information

NPI: 1396763504
Provider Name (Legal Business Name): JENNIFER M JOHNSON M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/17/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1035 ALTO STREET
SANTA FE NM
87501
US

IV. Provider business mailing address

1035 ALTO ST
SANTA FE NM
87501-2406
US

V. Phone/Fax

Practice location:
  • Phone: 505-982-4425
  • Fax: 505-982-6280
Mailing address:
  • Phone: 505-982-4425
  • Fax: 505-982-6280

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number87-268
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: