Provider Demographics
NPI:1528416229
Name:JOHNSON, JESSICA (CPHT)
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:CPHT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:110 METROPLEX BLVD
Mailing Address - Street 2:SUITE H
Mailing Address - City:PEARL
Mailing Address - State:MS
Mailing Address - Zip Code:39208-9210
Mailing Address - Country:US
Mailing Address - Phone:601-664-1664
Mailing Address - Fax:601-664-1661
Practice Address - Street 1:110 METROPLEX BLVD
Practice Address - Street 2:SUITE H
Practice Address - City:PEARL
Practice Address - State:MS
Practice Address - Zip Code:39208-9210
Practice Address - Country:US
Practice Address - Phone:601-664-1664
Practice Address - Fax:601-664-1661
Is Sole Proprietor?:No
Enumeration Date:2016-06-03
Last Update Date:2016-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MST0122183700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183700000XPharmacy Service ProvidersPharmacy Technician