Provider Demographics
NPI:1376137919
Name:JOHNSON, JESSICA ARCHER
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:ARCHER
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 1:158 COCHISE TRL
Mailing Address - Street 2:
Mailing Address - City:HAYDEN
Mailing Address - State:AL
Mailing Address - Zip Code:35079-8305
Mailing Address - Country:US
Mailing Address - Phone:205-266-8798
Mailing Address - Fax:
Practice Address - Street 1:158 COCHISE TRL
Practice Address - Street 2:
Practice Address - City:HAYDEN
Practice Address - State:AL
Practice Address - Zip Code:35079-8305
Practice Address - Country:US
Practice Address - Phone:205-266-8798
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-02-24
Last Update Date:2021-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL1-156708163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL1-156708OtherREGISTERED NURSE