Provider Demographics
NPI:1528360252
Name:JOHNSON, JESSE J (BMS)
Entity Type:Individual
Prefix:
First Name:JESSE
Middle Name:J
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:BMS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 28220
Mailing Address - Street 2:
Mailing Address - City:SANTA FE
Mailing Address - State:NM
Mailing Address - Zip Code:87592-8220
Mailing Address - Country:US
Mailing Address - Phone:505-471-5006
Mailing Address - Fax:
Practice Address - Street 1:130 N 2ND ST
Practice Address - Street 2:
Practice Address - City:RATON
Practice Address - State:NM
Practice Address - Zip Code:87740-3804
Practice Address - Country:US
Practice Address - Phone:575-445-3557
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-12-01
Last Update Date:2010-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor