Provider Demographics
NPI:1356636187
Name:JOHNSON, JESSICA
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:
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 1:4174 WESTPORT RD
Mailing Address - Street 2:T2473
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40207-2735
Mailing Address - Country:US
Mailing Address - Phone:502-992-1040
Mailing Address - Fax:502-992-1050
Practice Address - Street 1:4174 WESTPORT RD
Practice Address - Street 2:T2473
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40207-2735
Practice Address - Country:US
Practice Address - Phone:502-992-1040
Practice Address - Fax:502-992-1050
Is Sole Proprietor?:Yes
Enumeration Date:2011-06-09
Last Update Date:2011-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY014718183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist