Healthcare Provider Details

I. General information

NPI: 1043776503
Provider Name (Legal Business Name): JESSICA JOHNSON
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/20/2019
Last Update Date: 02/20/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3303 DUVAL ST
JUPITER FL
33458-8259
US

IV. Provider business mailing address

3303 DUVAL ST
JUPITER FL
33458-8259
US

V. Phone/Fax

Practice location:
  • Phone: 561-248-6875
  • Fax:
Mailing address:
  • Phone: 561-248-6875
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0200X
TaxonomyPediatric Nurse Practitioner
License Number2827222
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: