Provider Demographics
NPI:1407103898
Name:JOHNSON, JESSICA DANIELLE (APRN)
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:DANIELLE
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:234 WEST PORTER ST
Mailing Address - Street 2:
Mailing Address - City:MORGANTOWN
Mailing Address - State:KY
Mailing Address - Zip Code:42261
Mailing Address - Country:US
Mailing Address - Phone:270-526-9652
Mailing Address - Fax:270-526-9655
Practice Address - Street 1:234 WEST PORTER ST
Practice Address - Street 2:
Practice Address - City:MORGANTOWN
Practice Address - State:KY
Practice Address - Zip Code:42261
Practice Address - Country:US
Practice Address - Phone:270-526-9652
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-08-06
Last Update Date:2015-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY3007592363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
KYK15704Medicare PIN