Provider Demographics
NPI:1811032683
Name:JOHNSON, JESSICA T (NURSE PRACTITIONER)
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:T
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:NURSE PRACTITIONER
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9303 176TH PL NE UNIT 2
Mailing Address - Street 2:
Mailing Address - City:REDMOND
Mailing Address - State:WA
Mailing Address - Zip Code:98052-0813
Mailing Address - Country:US
Mailing Address - Phone:708-654-0321
Mailing Address - Fax:
Practice Address - Street 1:4115 FAIRVIEW AVE
Practice Address - Street 2:
Practice Address - City:DOWNERS GROVE
Practice Address - State:IL
Practice Address - Zip Code:60515-2268
Practice Address - Country:US
Practice Address - Phone:708-654-0321
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-02-20
Last Update Date:2022-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX197256164W00000X
WAAP61145807363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty
No164W00000XNursing Service ProvidersLicensed Practical NurseGroup - Single Specialty