1083680615 NPI number — DR. JENNIFER C ALLEN JOHNSON M.D.

Table of content: DR. JENNIFER C ALLEN JOHNSON M.D. (NPI 1083680615)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1083680615 NPI number — DR. JENNIFER C ALLEN JOHNSON M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
ALLEN JOHNSON
Provider First Name:
JENNIFER
Provider Middle Name:
C
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
M.D.
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
ALLEN
Provider Other First Name:
JENNIFER
Provider Other Middle Name:
CLAIRE
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
MD
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1083680615
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/27/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1005 MAR WALT DRIVE
Provider Second Line Business Mailing Address:
ADMINISTRATION
Provider Business Mailing Address City Name:
FORT WALTON BEACH
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
32547-6707
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
850-863-8100
Provider Business Mailing Address Fax Number:
850-863-4152

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
8990 NAVARRE PARKWAY
Provider Second Line Business Practice Location Address:
PEDIATRIC DEPARTMENT
Provider Business Practice Location Address City Name:
NAVARRE
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
32566-2216
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
850-396-0108
Provider Business Practice Location Address Fax Number:
850-939-4933
Provider Enumeration Date:
02/24/2006

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 2080A0000X , with the licence number:  00004512 , registered in the state of AL ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 208000000X , with the licence number: ME144527 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 009965240 , issued by the state of ( AL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 105928200 . This is a "Florida Medicaid Provider ID" identifier , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".