Provider Demographics
NPI:1568759983
Name:JOHNSON, JESSICA RODRIGUES (PA-C)
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:RODRIGUES
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:JESSICA
Other - Middle Name:MARIE
Other - Last Name:RODRIGUES
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:3555 LUTHERAN PARKWAY
Mailing Address - Street 2:SUITE 340
Mailing Address - City:WHEAT RIDGE
Mailing Address - State:CO
Mailing Address - Zip Code:80033
Mailing Address - Country:US
Mailing Address - Phone:303-996-6005
Mailing Address - Fax:303-420-8831
Practice Address - Street 1:3555 LUTHERAN PARKWAY
Practice Address - Street 2:SUITE 340
Practice Address - City:WHEAT RIDGE
Practice Address - State:CO
Practice Address - Zip Code:80033
Practice Address - Country:US
Practice Address - Phone:303-996-6005
Practice Address - Fax:303-420-8831
Is Sole Proprietor?:No
Enumeration Date:2011-07-06
Last Update Date:2020-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO3223363A00000X, 363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO23722321Medicaid