Provider Demographics
NPI:1710732177
Name:JOHNSON, JESSICA MARIE
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:MARIE
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 1:460 EVERGREEN RD
Mailing Address - Street 2:
Mailing Address - City:LAKE WYLIE
Mailing Address - State:SC
Mailing Address - Zip Code:29710-7055
Mailing Address - Country:US
Mailing Address - Phone:980-406-2479
Mailing Address - Fax:
Practice Address - Street 1:8410 W THOMAS RD STE 134
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85037-3374
Practice Address - Country:US
Practice Address - Phone:623-907-2377
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-04-19
Last Update Date:2024-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant