Provider Demographics
NPI:1801212675
Name:JOHNSON THOMAS, JODI RECHETTA (AGPCNP-BC)
Entity Type:Individual
Prefix:MRS
First Name:JODI
Middle Name:RECHETTA
Last Name:JOHNSON THOMAS
Suffix:
Gender:F
Credentials:AGPCNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:508 FULTON ST # 112
Mailing Address - Street 2:
Mailing Address - City:DURHAM
Mailing Address - State:NC
Mailing Address - Zip Code:27705-3875
Mailing Address - Country:US
Mailing Address - Phone:919-286-0411
Mailing Address - Fax:919-416-5857
Practice Address - Street 1:508 FULTON STREET #112
Practice Address - Street 2:
Practice Address - City:DUNHAN
Practice Address - State:NC
Practice Address - Zip Code:27705
Practice Address - Country:US
Practice Address - Phone:919-286-0411
Practice Address - Fax:919-416-5857
Is Sole Proprietor?:No
Enumeration Date:2014-03-17
Last Update Date:2016-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC5006753363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner