Provider Demographics
NPI:1902199821
Name:JOHNSON, JESSICA ALLISON (LM,CPM)
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:ALLISON
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:LM,CPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1221 SAM AVE
Mailing Address - Street 2:
Mailing Address - City:MODESTO
Mailing Address - State:CA
Mailing Address - Zip Code:95351-4617
Mailing Address - Country:US
Mailing Address - Phone:209-482-8682
Mailing Address - Fax:209-527-9737
Practice Address - Street 1:1221 SAM AVE
Practice Address - Street 2:
Practice Address - City:MODESTO
Practice Address - State:CA
Practice Address - Zip Code:95351-4617
Practice Address - Country:US
Practice Address - Phone:209-482-8682
Practice Address - Fax:209-527-9737
Is Sole Proprietor?:Yes
Enumeration Date:2011-05-25
Last Update Date:2011-05-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CALM305176B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes176B00000XOther Service ProvidersMidwife