Provider Demographics
NPI:1073205795
Name:JOHNSON, JESSIE LYNN (MFT)
Entity Type:Individual
Prefix:
First Name:JESSIE
Middle Name:LYNN
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:MFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5835 WISSAHICKON AVE
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19144-4446
Mailing Address - Country:US
Mailing Address - Phone:217-369-6793
Mailing Address - Fax:
Practice Address - Street 1:2133 ARCH ST STE 304
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19103-1350
Practice Address - Country:US
Practice Address - Phone:217-369-6793
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-05-22
Last Update Date:2023-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist