Provider Demographics
NPI:1255129615
Name:JOHNSON, JESSICA LYNN
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:LYNN
Last Name:JOHNSON
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:105 SCULLIN RD RD
Mailing Address - Street 2:
Mailing Address - City:BRASHER FALLS
Mailing Address - State:NY
Mailing Address - Zip Code:13613-4284
Mailing Address - Country:US
Mailing Address - Phone:518-521-4364
Mailing Address - Fax:
Practice Address - Street 1:1 CHIMNEY POINT DR
Practice Address - Street 2:
Practice Address - City:OGDENSBURG
Practice Address - State:NY
Practice Address - Zip Code:13669-2291
Practice Address - Country:US
Practice Address - Phone:315-541-2001
Practice Address - Fax:315-241-2008
Is Sole Proprietor?:Yes
Enumeration Date:2025-04-28
Last Update Date:2025-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY723963163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse