Provider Demographics
NPI:1508428301
Name:JOHNSON, JESSICA RAE (MD)
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:RAE
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:100 KINGS HWY S
Mailing Address - Street 2:
Mailing Address - City:ROCHESTER
Mailing Address - State:NY
Mailing Address - Zip Code:14617-5504
Mailing Address - Country:US
Mailing Address - Phone:585-922-0527
Mailing Address - Fax:585-922-0444
Practice Address - Street 1:2415 MASSACHUSETTS ST
Practice Address - Street 2:
Practice Address - City:LAWRENCE
Practice Address - State:KS
Practice Address - Zip Code:66046-4827
Practice Address - Country:US
Practice Address - Phone:785-832-4836
Practice Address - Fax:785-832-4887
Is Sole Proprietor?:No
Enumeration Date:2019-07-01
Last Update Date:2024-03-07
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MO2019023994208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics