Provider Demographics
NPI:1619691276
Name:JOHNSON, JESSICA E (RN)
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:E
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:JESSICA
Other - Middle Name:E
Other - Last Name:RAY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:400 TRACY WAY STE 100
Mailing Address - Street 2:
Mailing Address - City:CHARLESTON
Mailing Address - State:WV
Mailing Address - Zip Code:25311-1280
Mailing Address - Country:US
Mailing Address - Phone:304-720-0205
Mailing Address - Fax:304-720-0262
Practice Address - Street 1:400 TRACY WAY STE 100
Practice Address - Street 2:
Practice Address - City:CHARLESTON
Practice Address - State:WV
Practice Address - Zip Code:25311-1280
Practice Address - Country:US
Practice Address - Phone:304-720-0205
Practice Address - Fax:304-720-0262
Is Sole Proprietor?:No
Enumeration Date:2022-09-28
Last Update Date:2022-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV103305163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse