Healthcare Provider Details

I. General information

NPI: 1235304643
Provider Name (Legal Business Name): JENNIFER JOHNSON
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/25/2008
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11216 SUNRISE BLVD E STE 3-203
PUYALLUP WA
98374-8848
US

IV. Provider business mailing address

16115 CAMDEN DR E
PUYALLUP WA
98375-9601
US

V. Phone/Fax

Practice location:
  • Phone: 253-852-2828
  • Fax:
Mailing address:
  • Phone: 206-304-0330
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number1111N0000X
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: