Provider Demographics
NPI:1003359951
Name:JOHNSON, JACQUELINE (AGNP)
Entity type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:AGNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3525 W HOLCOMBE BLVD
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77025-1313
Mailing Address - Country:US
Mailing Address - Phone:713-814-2800
Mailing Address - Fax:
Practice Address - Street 1:822 RED TIP DR
Practice Address - Street 2:
Practice Address - City:ALLEN
Practice Address - State:TX
Practice Address - Zip Code:75002-5023
Practice Address - Country:US
Practice Address - Phone:501-416-8045
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-11-27
Last Update Date:2025-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX81-4360797163W00000X, 376K00000X, 164X00000X
TXAP143029363LG0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology
No163W00000XNursing Service ProvidersRegistered Nurse
No376K00000XNursing Service Related ProvidersNurse's Aide
No164X00000XNursing Service ProvidersLicensed Vocational Nurse