Provider Demographics
NPI:1265833545
Name:JOHNSON, JESSICA L (PA-C)
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:L
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 1:4460 BROAD ST STE A
Mailing Address - Street 2:
Mailing Address - City:SAN LUIS OBISPO
Mailing Address - State:CA
Mailing Address - Zip Code:93401-8064
Mailing Address - Country:US
Mailing Address - Phone:805-597-6715
Mailing Address - Fax:805-541-4973
Practice Address - Street 1:4460 BROAD ST STE A
Practice Address - Street 2:
Practice Address - City:SAN LUIS OBISPO
Practice Address - State:CA
Practice Address - Zip Code:93401
Practice Address - Country:US
Practice Address - Phone:805-597-6715
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-09-05
Last Update Date:2023-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA51891363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant