Provider Demographics
NPI:1740516251
Name:JOHNSON, JACKIE ANN
Entity type:Individual
Prefix:
First Name:JACKIE
Middle Name:ANN
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:JACKIE
Other - Middle Name:ANN
Other - Last Name:WILBERT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:DEPT 888182
Mailing Address - Street 2:
Mailing Address - City:KNOXVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37995-8182
Mailing Address - Country:US
Mailing Address - Phone:800-355-3565
Mailing Address - Fax:423-714-2355
Practice Address - Street 1:627 SMITHVIEW DR
Practice Address - Street 2:
Practice Address - City:MARYVILLE
Practice Address - State:TN
Practice Address - Zip Code:37803-6100
Practice Address - Country:US
Practice Address - Phone:865-380-4390
Practice Address - Fax:865-380-4396
Is Sole Proprietor?:No
Enumeration Date:2009-10-19
Last Update Date:2009-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNLPN69057164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse