Provider Demographics
NPI:1942726013
Name:INNOCENT - JOHNSON, JESSICA
Entity Type:Individual
Prefix:MS
First Name:JESSICA
Middle Name:
Last Name:INNOCENT - 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 1:5254 SUNRISE HWY
Mailing Address - Street 2:
Mailing Address - City:MASSAPEQUA PARK
Mailing Address - State:NY
Mailing Address - Zip Code:11762-2907
Mailing Address - Country:US
Mailing Address - Phone:516-691-0401
Mailing Address - Fax:
Practice Address - Street 1:5254 SUNRISE HWY
Practice Address - Street 2:
Practice Address - City:MASSAPEQUA PARK
Practice Address - State:NY
Practice Address - Zip Code:11762-2907
Practice Address - Country:US
Practice Address - Phone:516-691-0401
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-08-20
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist