Provider Demographics
NPI:1831860162
Name:JOHNSON, JACQUELYNN MELISSA SMITH (CNM)
Entity type:Individual
Prefix:
First Name:JACQUELYNN
Middle Name:MELISSA SMITH
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:CNM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:601 MEMORY LN
Mailing Address - Street 2:
Mailing Address - City:YORK
Mailing Address - State:PA
Mailing Address - Zip Code:17402-2231
Mailing Address - Country:US
Mailing Address - Phone:717-851-1405
Mailing Address - Fax:
Practice Address - Street 1:13515 WOLFE RD
Practice Address - Street 2:
Practice Address - City:NEW FREEDOM
Practice Address - State:PA
Practice Address - Zip Code:17349-9346
Practice Address - Country:US
Practice Address - Phone:717-812-2540
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-09-27
Last Update Date:2025-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDR211303176B00000X
367A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice Midwife
No176B00000XOther Service ProvidersMidwife