Healthcare Provider Details

I. General information

NPI: 1093353393
Provider Name (Legal Business Name): JENNIFER JOHNSON CPSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/17/2019
Last Update Date: 02/19/2020
Certification Date: 02/19/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

614 MCADOO ST STE B
T OR C NM
87901-2706
US

IV. Provider business mailing address

614 MCADOO ST STE B
T OR C NM
87901-2706
US

V. Phone/Fax

Practice location:
  • Phone: 575-297-0171
  • Fax:
Mailing address:
  • Phone: 575-297-0171
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code175T00000X
TaxonomyPeer Specialist
License Number1009
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: