Provider Demographics
NPI:1639464076
Name:JOHNSON, JESSICA L (MD)
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:L
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:WRAMC BLDG 2 RM 2G01
Mailing Address - Street 2:6900 GEORGIA AVE NW
Mailing Address - City:WASHINGTON
Mailing Address - State:DC
Mailing Address - Zip Code:20307-0001
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:790 COLLEGE PKWY
Practice Address - Street 2:
Practice Address - City:COLCHESTER
Practice Address - State:VT
Practice Address - Zip Code:05446-3007
Practice Address - Country:US
Practice Address - Phone:802-847-0318
Practice Address - Fax:802-847-6846
Is Sole Proprietor?:No
Enumeration Date:2011-06-14
Last Update Date:2019-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
VT042.0014416208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program