Healthcare Provider Details

I. General information

NPI: 1396397113
Provider Name (Legal Business Name): JESSICA LYNN JOHNSON
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/11/2019
Last Update Date: 04/28/2022
Certification Date: 04/28/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3710 E 20TH AVE
ANCHORAGE AK
99508-3418
US

IV. Provider business mailing address

118 BURTON ST APT B
ANCHORAGE AK
99504-1203
US

V. Phone/Fax

Practice location:
  • Phone: 907-222-7300
  • Fax:
Mailing address:
  • Phone: 907-312-0643
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: