Provider Demographics
NPI:1861169252
Name:JOHNSON, JERVONNE LANEE
Entity type:Individual
Prefix:
First Name:JERVONNE
Middle Name:LANEE
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:30 PALATINE APT 338
Mailing Address - Street 2:
Mailing Address - City:IRVINE
Mailing Address - State:CA
Mailing Address - Zip Code:92612-8864
Mailing Address - Country:US
Mailing Address - Phone:213-304-6050
Mailing Address - Fax:
Practice Address - Street 1:5901 W CENTURY BLVD STE 750
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90045-5443
Practice Address - Country:US
Practice Address - Phone:888-880-3451
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-08-24
Last Update Date:2024-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95018172363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily