Provider Demographics
NPI:1790076289
Name:JOHNSON, JESSICA (DPM)
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1014 LOWDEN RD
Mailing Address - Street 2:
Mailing Address - City:STREATOR
Mailing Address - State:IL
Mailing Address - Zip Code:61364-1418
Mailing Address - Country:US
Mailing Address - Phone:815-674-0980
Mailing Address - Fax:
Practice Address - Street 1:1014 LOWDEN RD
Practice Address - Street 2:
Practice Address - City:STREATOR
Practice Address - State:IL
Practice Address - Zip Code:61364-1418
Practice Address - Country:US
Practice Address - Phone:815-674-0980
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-05-02
Last Update Date:2014-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPO 3668213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery