Healthcare Provider Details

I. General information

NPI: 1225846173
Provider Name (Legal Business Name): JESSICA JOHNSON AGPCNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/24/2024
Last Update Date: 06/14/2025
Certification Date: 06/14/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

615 E VILLANOW ST
LA FAYETTE GA
30728-2618
US

IV. Provider business mailing address

615 E VILLANOW ST
LA FAYETTE GA
30728-2618
US

V. Phone/Fax

Practice location:
  • Phone: 706-638-1606
  • Fax:
Mailing address:
  • Phone: 706-638-1606
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number37238
License Number StateTN
# 2
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License NumberRN294745
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: