Provider Demographics
NPI:1740331172
Name:JOHNSON, JESSICA L (LPN)
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:L
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:JESSICA
Other - Middle Name:L
Other - Last Name:JOSLYN
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:LPN
Mailing Address - Street 1:PO BOX 214
Mailing Address - Street 2:
Mailing Address - City:DURHAMVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:13054-0214
Mailing Address - Country:US
Mailing Address - Phone:315-361-9684
Mailing Address - Fax:
Practice Address - Street 1:348 MAPLE ST
Practice Address - Street 2:
Practice Address - City:ONEIDA
Practice Address - State:NY
Practice Address - Zip Code:13421-2129
Practice Address - Country:US
Practice Address - Phone:315-363-8105
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-14
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY10259165164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02225529Medicaid