Provider Demographics
NPI:1184220758
Name:JOHNSON, JESSICA LYNN
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:LYNN
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:PO BOX 68
Mailing Address - Street 2:
Mailing Address - City:MIDDLEBOURNE
Mailing Address - State:WV
Mailing Address - Zip Code:26149-0068
Mailing Address - Country:US
Mailing Address - Phone:304-758-4919
Mailing Address - Fax:304-758-4680
Practice Address - Street 1:504 CHERRY ST
Practice Address - Street 2:
Practice Address - City:MIDDLEBOURNE
Practice Address - State:WV
Practice Address - Zip Code:26149-9618
Practice Address - Country:US
Practice Address - Phone:304-758-4919
Practice Address - Fax:304-758-4680
Is Sole Proprietor?:No
Enumeration Date:2020-12-09
Last Update Date:2020-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes376J00000XNursing Service Related ProvidersHomemaker