MEDICARE: MRS. JULIE JACKSON JOHNSON PA-C

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363A00000X	Physician Assistant	2615	CO

General Provider Information

NPI Number	:	1417112343
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. JULIE JACKSON JOHNSON PA-C

Provider Business Mailing Address
First Line	:	175 S UNION BLVD
Second Line	:	STE 350
City	:	COLORADO SPRINGS
State	:	CO
Zip	:	80910-3146
Country	:	US
Telephone Number	:	719-590-7007
Fax Number	:	719-590-7037

Provider Business Practice Location Address
First Line	:	2130 HOLLOW BROOK DR
Second Line	:	SUITE #100
City	:	COLORADO SPRINGS
State	:	CO
Zip	:	80918-8400
Country	:	US
Telephone Number	:	719-590-7007
Fax Number	:	719-590-7037

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/21/2008
Last Update Date	:	02/09/2017

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