Provider Demographics
NPI:1831734938
Name:JOHNSON, JESSICA (A)
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:A
Other - Prefix:MISS
Other - First Name:JESSICA
Other - Middle Name:
Other - Last Name:JOHNSON
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:56478 S 590 RD
Mailing Address - Street 2:
Mailing Address - City:KANSAS
Mailing Address - State:OK
Mailing Address - Zip Code:74347-1654
Mailing Address - Country:US
Mailing Address - Phone:918-718-0911
Mailing Address - Fax:
Practice Address - Street 1:5555 S LEWIS AVE
Practice Address - Street 2:
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74105-7104
Practice Address - Country:US
Practice Address - Phone:918-216-0450
Practice Address - Fax:918-205-9036
Is Sole Proprietor?:No
Enumeration Date:2019-11-12
Last Update Date:2019-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator