Provider Demographics
NPI:1053692442
Name:JOHNSON, JESSICA ANN (LMP)
Entity type:Individual
Prefix:MS
First Name:JESSICA
Middle Name:ANN
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:LMP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:628 S MAPLE ST
Mailing Address - Street 2:SUITE B
Mailing Address - City:SPOKANE
Mailing Address - State:WA
Mailing Address - Zip Code:99204-3445
Mailing Address - Country:US
Mailing Address - Phone:509-979-9019
Mailing Address - Fax:
Practice Address - Street 1:628 S MAPLE ST
Practice Address - Street 2:SUITE B
Practice Address - City:SPOKANE
Practice Address - State:WA
Practice Address - Zip Code:99204-3445
Practice Address - Country:US
Practice Address - Phone:509-979-9019
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-08-30
Last Update Date:2012-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA 60127280174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist