Provider Demographics
NPI:1922417898
Name:JOHNSON, JESSICA LYN
Entity Type:Individual
Prefix:MRS
First Name:JESSICA
Middle Name:LYN
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3963 MAIDSTONE DR
Mailing Address - Street 2:
Mailing Address - City:GAHANNA
Mailing Address - State:OH
Mailing Address - Zip Code:43230-4513
Mailing Address - Country:US
Mailing Address - Phone:614-316-8046
Mailing Address - Fax:
Practice Address - Street 1:3963 MAIDSTONE DR
Practice Address - Street 2:
Practice Address - City:GAHANNA
Practice Address - State:OH
Practice Address - Zip Code:43230-4513
Practice Address - Country:US
Practice Address - Phone:614-316-8046
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-08-05
Last Update Date:2014-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes372500000XNursing Service Related ProvidersChore Provider
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2905146Medicaid