Provider Demographics
NPI:1366838112
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 1:1006 BRIARCLIFF DR
Mailing Address - Street 2:
Mailing Address - City:MAHOMET
Mailing Address - State:IL
Mailing Address - Zip Code:61853-9766
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:611 W. PARK ST.
Practice Address - Street 2:FAPC
Practice Address - City:URBANA
Practice Address - State:IL
Practice Address - Zip Code:61801
Practice Address - Country:US
Practice Address - Phone:217-902-5291
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-04-08
Last Update Date:2018-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM390200000X
IL036146931207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program