Provider Demographics
NPI:1679157176
Name:JOHNSON, JESSICA
Entity Type:Individual
Prefix:MRS
First Name:JESSICA
Middle Name:
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:800 N RAINBOW BLVD STE 215
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89107-1189
Mailing Address - Country:US
Mailing Address - Phone:800-950-0026
Mailing Address - Fax:702-952-5257
Practice Address - Street 1:800 N RAINBOW BLVD STE 215
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89107-1189
Practice Address - Country:US
Practice Address - Phone:800-950-0026
Practice Address - Fax:702-952-5257
Is Sole Proprietor?:No
Enumeration Date:2021-05-11
Last Update Date:2024-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1037055363LP0808X
NV868970363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health