Provider Demographics
NPI:1053349308
Name:JOHNSON, JEANETTE (OT R/L)
Entity type:Individual
Prefix:MRS
First Name:JEANETTE
Middle Name:
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:OT R/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2208 N YELLOWOOD AVE
Mailing Address - Street 2:
Mailing Address - City:BROKEN ARROW
Mailing Address - State:OK
Mailing Address - Zip Code:74012-9102
Mailing Address - Country:US
Mailing Address - Phone:918-286-1261
Mailing Address - Fax:918-286-1265
Practice Address - Street 1:2208 N YELLOWOOD AVE
Practice Address - Street 2:
Practice Address - City:BROKEN ARROW
Practice Address - State:OK
Practice Address - Zip Code:74012-9102
Practice Address - Country:US
Practice Address - Phone:918-286-1261
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-28
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK500174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist