Healthcare Provider Details

I. General information

NPI: 1134612500
Provider Name (Legal Business Name): JILL JOHNSTON AGACNP-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/11/2018
Last Update Date: 03/31/2026
Certification Date: 03/31/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1111 N CHINA LAKE BLVD STE 190
RIDGECREST CA
93555-3131
US

IV. Provider business mailing address

1081 N CHINA LAKE BLVD
RIDGECREST CA
93555-3130
US

V. Phone/Fax

Practice location:
  • Phone: 760-499-3855
  • Fax: 760-499-3870
Mailing address:
  • Phone: 760-499-3899
  • Fax: 760-499-3870

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LA2100X
TaxonomyAcute Care Nurse Practitioner
License NumberAP60863423
License Number StateWA
# 2
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License NumberAP60863423
License Number StateWA
# 3
Primary TaxonomyN
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License NumberAP60863423
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: