Provider Demographics
NPI:1720595945
Name:JOHNSON, JESSICA
Entity Type:Individual
Prefix:
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 1:3110 CAMINO DEL RIO S STE 307
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92108-3832
Mailing Address - Country:US
Mailing Address - Phone:619-795-9925
Mailing Address - Fax:
Practice Address - Street 1:10400 NE 4TH ST STE 500
Practice Address - Street 2:
Practice Address - City:BELLEVUE
Practice Address - State:WA
Practice Address - Zip Code:98004-5175
Practice Address - Country:US
Practice Address - Phone:425-559-7809
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-01-09
Last Update Date:2018-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician