Provider Demographics
NPI:1548733785
Name:JOHNSON, JESSICA THORMAN (MS, RD, LD)
Entity Type:Individual
Prefix:MRS
First Name:JESSICA
Middle Name:THORMAN
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:MS, RD, LD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1056 TEXAN TRAIL (FORTIS BMI)
Mailing Address - Street 2:
Mailing Address - City:GRAPEVINE
Mailing Address - State:TX
Mailing Address - Zip Code:76051
Mailing Address - Country:US
Mailing Address - Phone:817-251-0070
Mailing Address - Fax:817-527-6610
Practice Address - Street 1:1056 TEXAN TRAIL (FORTIS BMI)
Practice Address - Street 2:
Practice Address - City:GRAPEVINE
Practice Address - State:TX
Practice Address - Zip Code:76051
Practice Address - Country:US
Practice Address - Phone:817-251-0070
Practice Address - Fax:817-527-6610
Is Sole Proprietor?:No
Enumeration Date:2019-01-10
Last Update Date:2019-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXDT84348133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered