Provider Demographics
NPI:1154164671
Name:JOHNSON, JESSICA (TRT)
Entity type:Individual
Prefix:MRS
First Name:JESSICA
Middle Name:
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:TRT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3520 S HIGHLAND DR
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84106-3211
Mailing Address - Country:US
Mailing Address - Phone:801-520-3622
Mailing Address - Fax:
Practice Address - Street 1:3520 S HIGHLAND DR
Practice Address - Street 2:
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84106-3211
Practice Address - Country:US
Practice Address - Phone:801-520-3622
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-06-13
Last Update Date:2024-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT13398813-4003226000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes226000000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRecreational Therapist Assistant