Healthcare Provider Details

I. General information

NPI: 1275203549
Provider Name (Legal Business Name): JESSICA TYNEA JOHNSON
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/17/2021
Last Update Date: 01/31/2025
Certification Date: 01/31/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

115 DUNMORELAND ST
SPRINGFIELD MA
01109-3261
US

IV. Provider business mailing address

115 DUNMORELAND ST
SPRINGFIELD MA
01109-3261
US

V. Phone/Fax

Practice location:
  • Phone: 413-219-3689
  • Fax:
Mailing address:
  • Phone: 413-219-3689
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WG0000X
TaxonomyGeneral Practice Registered Nurse
License NumberRN2388726
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: