MEDICARE: MS. JENNIFER ELLEN JOHNSON

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	101Y00000X	Counselor

General Provider Information

NPI Number	:	1487125464
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. JENNIFER ELLEN JOHNSON

Provider Business Mailing Address
First Line	:	614 HAVEN LN
Second Line	:
City	:	CLARKS SUMMIT
State	:	PA
Zip	:	18411-2402
Country	:	US
Telephone Number	:	831-578-9775
Fax Number	:

Provider Business Practice Location Address
First Line	:	614 HAVEN LN
Second Line	:
City	:	CLARKS SUMMIT
State	:	PA
Zip	:	18411-2402
Country	:	US
Telephone Number	:	831-578-9775
Fax Number	:

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

Provider Enumeration Date	:	12/17/2018
Last Update Date	:	12/17/2018

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