MEDICARE: JACQUELINE JOHNSON FNP-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	363LF0000X	Family Nurse Practitioner	21596	SC

General Provider Information

NPI Number	:	1548760515
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JACQUELINE JOHNSON FNP-C

Provider Business Mailing Address
First Line	:	1309 WILD OLIVE DR
Second Line	:
City	:	MT PLEASANT
State	:	SC
Zip	:	29464-7478
Country	:	US
Telephone Number	:	276-494-4449
Fax Number	:

Provider Business Practice Location Address
First Line	:	725 LONG POINT RD
Second Line	:
City	:	MT PLEASANT
State	:	SC
Zip	:	29464-8226
Country	:	US
Telephone Number	:	276-494-4449
Fax Number	:	276-494-4449

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

Provider Enumeration Date	:	02/16/2018
Last Update Date	:	02/16/2018

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