Healthcare Provider Details

I. General information

NPI: 1891988317
Provider Name (Legal Business Name): JESSICA ELAINE JOHNSON RN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/20/2007
Last Update Date: 07/31/2020
Certification Date: 07/31/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

125 W MISSION AVE STE. 103
ESCONDIDO CA
92025-1720
US

IV. Provider business mailing address

125 W MISSION AVE STE. 103
ESCONDIDO CA
92025-1720
US

V. Phone/Fax

Practice location:
  • Phone: 760-747-3424
  • Fax: 760-747-3435
Mailing address:
  • Phone: 760-747-3424
  • Fax: 760-747-3435

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code164X00000X
TaxonomyLicensed Vocational Nurse
License NumberVN 226642
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code163WP0808X
TaxonomyPsychiatric/Mental Health Registered Nurse
License Number95205010
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: