Provider Demographics
NPI:1235193095
Name:JOHNSON, JESSICA S (COTA/L)
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:S
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:COTA/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1130 LINCOLN RD
Mailing Address - Street 2:
Mailing Address - City:MARYVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37804-3066
Mailing Address - Country:US
Mailing Address - Phone:865-659-0615
Mailing Address - Fax:
Practice Address - Street 1:201 W SPRINGDALE AVE
Practice Address - Street 2:
Practice Address - City:KNOXVILLE
Practice Address - State:TN
Practice Address - Zip Code:37917-5158
Practice Address - Country:US
Practice Address - Phone:865-637-9711
Practice Address - Fax:865-637-4362
Is Sole Proprietor?:No
Enumeration Date:2006-04-17
Last Update Date:2022-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YM0800X
TN3862224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health