Provider Demographics
NPI:1932956158
Name:JOHNSON, JESSICA NICHOLE (CPM, LDM)
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:NICHOLE
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:CPM, LDM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:309 SE DAYTON AVE
Mailing Address - Street 2:
Mailing Address - City:MCMINNVILLE
Mailing Address - State:OR
Mailing Address - Zip Code:97128-6217
Mailing Address - Country:US
Mailing Address - Phone:971-241-2085
Mailing Address - Fax:
Practice Address - Street 1:309 SE DAYTON AVE
Practice Address - Street 2:
Practice Address - City:MCMINNVILLE
Practice Address - State:OR
Practice Address - Zip Code:97128-6217
Practice Address - Country:US
Practice Address - Phone:971-241-2085
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-05-06
Last Update Date:2024-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORDEM-LD-10242979176B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes176B00000XOther Service ProvidersMidwife