1285059774 NPI number — JESSICA LYNN JOHNSON DO

Table of content: JESSICA LYNN JOHNSON DO (NPI 1285059774)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1285059774 NPI number — JESSICA LYNN JOHNSON DO

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
JOHNSON
Provider First Name:
JESSICA
Provider Middle Name:
LYNN
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
DO
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
CLARK
Provider Other First Name:
JESSICA
Provider Other Middle Name:
LYNN
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
DO
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1285059774
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
02/07/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
300 E MCBEE AVE FL 4
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
GREENVILLE
Provider Business Mailing Address State Name:
SC
Provider Business Mailing Address Postal Code:
29601-2842
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
864-522-8611
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
11082 N RADIO STATION RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SENECA
Provider Business Practice Location Address State Name:
SC
Provider Business Practice Location Address Postal Code:
29678
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
864-882-2314
Provider Business Practice Location Address Fax Number:
843-882-3677
Provider Enumeration Date:
02/20/2014

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X , with the licence number:  36682 , registered in the state of SC ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 366820 , issued by the state of ( SC ) . This identifiers is of the category "MEDICAID".




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