Provider Demographics
NPI:1639137821
Name:JOHNSON, JODI L (CRNP)
Entity type:Individual
Prefix:
First Name:JODI
Middle Name:L
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:CRNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1700 BENT CREEK BLVD STE 210
Mailing Address - Street 2:
Mailing Address - City:MECHANICSBURG
Mailing Address - State:PA
Mailing Address - Zip Code:17050-1870
Mailing Address - Country:US
Mailing Address - Phone:717-791-2640
Mailing Address - Fax:717-791-2646
Practice Address - Street 1:1700 BENT CREEK BLVD STE 210
Practice Address - Street 2:
Practice Address - City:MECHANICSBURG
Practice Address - State:PA
Practice Address - Zip Code:17050-1870
Practice Address - Country:US
Practice Address - Phone:717-791-2640
Practice Address - Fax:717-791-2646
Is Sole Proprietor?:No
Enumeration Date:2006-05-04
Last Update Date:2024-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PASP007500363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA50001116OtherCAPITAL BLUE CROSS IND
PAP98857Medicare UPIN
PA073584 R4BMedicare ID - Type UnspecifiedMEDICARE INDIVIDUAL