Provider Demographics
NPI:1619975455
Name:JOHNSON, JESSE B (CRNA)
Entity Type:Individual
Prefix:
First Name:JESSE
Middle Name:B
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:601 W MAPLE AVE STE 503
Mailing Address - Street 2:
Mailing Address - City:SPRINGDALE
Mailing Address - State:AR
Mailing Address - Zip Code:72764-5376
Mailing Address - Country:US
Mailing Address - Phone:479-751-3722
Mailing Address - Fax:479-751-1099
Practice Address - Street 1:609 W MAPLE AVE
Practice Address - Street 2:
Practice Address - City:SPRINGDALE
Practice Address - State:AR
Practice Address - Zip Code:72764-5335
Practice Address - Country:US
Practice Address - Phone:479-751-5711
Practice Address - Fax:479-751-1099
Is Sole Proprietor?:No
Enumeration Date:2005-07-13
Last Update Date:2022-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX621415367500000X
ARC001215367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX002959701Medicaid
AR139829701Medicaid
TX83751HOtherBLUE CROSS
AR98519OtherBLUE CROSS
TX83751HMedicare ID - Type Unspecified
AR98519OtherBLUE CROSS
S47481Medicare UPIN