Healthcare Provider Details

I. General information

NPI: 1154636975
Provider Name (Legal Business Name): MRS. JENNIFER LYNN JOHNSON
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/17/2010
Last Update Date: 08/17/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

94 E PAGES LN A
CENTERVILLE UT
84014-2216
US

IV. Provider business mailing address

602 E 1200 S
KAYSVILLE UT
84037-4020
US

V. Phone/Fax

Practice location:
  • Phone: 801-294-0578
  • Fax:
Mailing address:
  • Phone: 801-451-0845
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: