Healthcare Provider Details

I. General information

NPI: 1457401747
Provider Name (Legal Business Name): JENNIFER L JOHNSON O.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/11/2007
Last Update Date: 09/14/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

124 E BANDERA RD STE 403
BOERNE TX
78006-2849
US

IV. Provider business mailing address

124 E BANDERA RD STE 403
BOERNE TX
78006-2849
US

V. Phone/Fax

Practice location:
  • Phone: 830-331-8745
  • Fax: 866-897-9855
Mailing address:
  • Phone: 830-331-8745
  • Fax: 866-897-9855

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number5869TG
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: