Provider Demographics
NPI:1447534672
Name:JOHNSON, JODI LYNN (PA-C)
Entity type:Individual
Prefix:MRS
First Name:JODI
Middle Name:LYNN
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:710 COLONIAL DR
Mailing Address - Street 2:
Mailing Address - City:BATON ROUGE
Mailing Address - State:LA
Mailing Address - Zip Code:70806-6511
Mailing Address - Country:US
Mailing Address - Phone:225-927-5325
Mailing Address - Fax:225-927-4150
Practice Address - Street 1:710 COLONIAL DR
Practice Address - Street 2:
Practice Address - City:BATON ROUGE
Practice Address - State:LA
Practice Address - Zip Code:70806-6511
Practice Address - Country:US
Practice Address - Phone:225-927-5325
Practice Address - Fax:225-927-4150
Is Sole Proprietor?:Yes
Enumeration Date:2011-10-06
Last Update Date:2021-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAPA200507363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant