Healthcare Provider Details

I. General information

NPI: 1902199821
Provider Name (Legal Business Name): JESSICA ALLISON JOHNSON LM,CPM
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/25/2011
Last Update Date: 05/25/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1221 SAM AVE
MODESTO CA
95351-4617
US

IV. Provider business mailing address

1221 SAM AVE
MODESTO CA
95351-4617
US

V. Phone/Fax

Practice location:
  • Phone: 209-482-8682
  • Fax: 209-527-9737
Mailing address:
  • Phone: 209-482-8682
  • Fax: 209-527-9737

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code176B00000X
TaxonomyMidwife
License NumberLM305
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: