Provider Demographics
NPI:1659680700
Name:JOHNSON, JESSICA ANN (UMT)
Entity Type:Individual
Prefix:MRS
First Name:JESSICA
Middle Name:ANN
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:UMT
Other - Prefix:MS
Other - First Name:JESSICA
Other - Middle Name:ANN
Other - Last Name:SLATER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:314 GOFF MOUNTAIN RD.
Mailing Address - Street 2:SUITE 13
Mailing Address - City:CROSS LANES
Mailing Address - State:WV
Mailing Address - Zip Code:25313
Mailing Address - Country:US
Mailing Address - Phone:304-776-5031
Mailing Address - Fax:304-204-6332
Practice Address - Street 1:314 GOFF MOUNTAIN ROAD
Practice Address - Street 2:SUITE 13
Practice Address - City:CROSS LANES
Practice Address - State:WV
Practice Address - Zip Code:25313
Practice Address - Country:US
Practice Address - Phone:304-776-5031
Practice Address - Fax:304-204-6332
Is Sole Proprietor?:No
Enumeration Date:2010-10-06
Last Update Date:2010-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV593400-10225700000X
WV2010-2725225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist