Provider Demographics
NPI:1184853764
Name:JOHNSON, JESSICA ELIZABETH
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:ELIZABETH
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 1:3105 CREEKSIDE VILLAGE DR NW STE 603
Mailing Address - Street 2:
Mailing Address - City:KENNESAW
Mailing Address - State:GA
Mailing Address - Zip Code:30144-4218
Mailing Address - Country:US
Mailing Address - Phone:770-974-2424
Mailing Address - Fax:866-384-6451
Practice Address - Street 1:3105 CREEKSIDE VILLAGE DR NW STE 603
Practice Address - Street 2:
Practice Address - City:KENNESAW
Practice Address - State:GA
Practice Address - Zip Code:30144-4218
Practice Address - Country:US
Practice Address - Phone:770-974-2424
Practice Address - Fax:866-384-6451
Is Sole Proprietor?:No
Enumeration Date:2009-07-05
Last Update Date:2009-07-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GASLP007099235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist