Healthcare Provider Details

I. General information

NPI: 1427755883
Provider Name (Legal Business Name): JESSICA JOHNSON CRNP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/15/2023
Last Update Date: 09/11/2024
Certification Date: 09/11/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

600 WYNDHURST AVE STE 307D
BALTIMORE MD
21210-2419
US

IV. Provider business mailing address

9724 MORNINGVIEW CIR
PERRY HALL MD
21128-9024
US

V. Phone/Fax

Practice location:
  • Phone: 443-695-1107
  • Fax:
Mailing address:
  • Phone: 443-695-0409
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberR236457
License Number StateMD
# 2
Primary TaxonomyN
Taxonomy Code363LW0102X
TaxonomyWomen's Health Nurse Practitioner
License NumberR236457
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: