Provider Demographics
NPI:1922416056
Name:JOHNSON, JESSICA RICHASON (MHA, DPM)
Entity Type:Individual
Prefix:DR
First Name:JESSICA
Middle Name:RICHASON
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:MHA, DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1201 BROAD ROCK BLVD
Mailing Address - Street 2:
Mailing Address - City:RICHMOND
Mailing Address - State:VA
Mailing Address - Zip Code:23224-4915
Mailing Address - Country:US
Mailing Address - Phone:804-675-4765
Mailing Address - Fax:
Practice Address - Street 1:1201 BROAD ROCK BLVD
Practice Address - Street 2:
Practice Address - City:RICHMOND
Practice Address - State:VA
Practice Address - Zip Code:23224-4915
Practice Address - Country:US
Practice Address - Phone:804-675-4765
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-08-01
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0116027528213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO1922416056Medicaid