Provider Demographics
NPI:1750044723
Name:JOHNSEN, JESSICA
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:
Last Name:JOHNSEN
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 1:2681 ROUTE 394
Mailing Address - Street 2:
Mailing Address - City:CRETE
Mailing Address - State:IL
Mailing Address - Zip Code:60417-4353
Mailing Address - Country:US
Mailing Address - Phone:708-672-6777
Mailing Address - Fax:708-672-8914
Practice Address - Street 1:2681 ROUTE 394
Practice Address - Street 2:
Practice Address - City:CRETE
Practice Address - State:IL
Practice Address - Zip Code:60417-4353
Practice Address - Country:US
Practice Address - Phone:708-672-6777
Practice Address - Fax:708-672-8914
Is Sole Proprietor?:No
Enumeration Date:2021-10-18
Last Update Date:2021-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL041394669163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse