Healthcare Provider Details

I. General information

NPI: 1841823093
Provider Name (Legal Business Name): JENNIFER D JOHNSON
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/17/2020
Last Update Date: 10/28/2022
Certification Date: 10/28/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1624 CIMARRON PLZ
STILLWATER OK
74075-3467
US

IV. Provider business mailing address

1624 CIMARRON PLZ
STILLWATER OK
74075-3467
US

V. Phone/Fax

Practice location:
  • Phone: 405-372-2202
  • Fax: 405-372-2237
Mailing address:
  • Phone: 405-372-2202
  • Fax: 405-372-2237

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number10935
License Number StateOK
# 2
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number2020004767
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: