Basic Information
| Provider Information | |||||||||
| NPI: | 1174502918 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | JOHNSON | ||||||||
| FirstName: | JENIFER | ||||||||
| MiddleName: | M | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1 THEALL RD | ||||||||
| Address2: | |||||||||
| City: | RYE | ||||||||
| State: | NY | ||||||||
| PostalCode: | 105801404 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9148488700 | ||||||||
| FaxNumber: | 9148488701 | ||||||||
| Practice Location | |||||||||
| Address1: | 1 THEALL RD | ||||||||
| Address2: | |||||||||
| City: | RYE | ||||||||
| State: | NY | ||||||||
| PostalCode: | 105801404 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9148488700 | ||||||||
| FaxNumber: | 9148488701 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/11/2006 | ||||||||
| LastUpdateDate: | 07/29/2014 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 236084 | NY | Y | Allopathic & Osteopathic Physicians | Family Medicine | 207Q00000X | 053095 | CT | N | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 02703148 | 05 | NY | MEDICAID | 236084-01 CFP | 01 | NY | WORKERS COMPENSATION | OTHER |