Healthcare Provider Details

I. General information

NPI: 1174449128
Provider Name (Legal Business Name): JESSICA L JOHNSON
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/25/2026
Last Update Date: 06/25/2026
Certification Date: 06/25/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

603 S BISHOP AVE STE C
ROLLA MO
65401-4320
US

IV. Provider business mailing address

15945 COUNTY ROAD 8140
ROLLA MO
65401-5253
US

V. Phone/Fax

Practice location:
  • Phone: 573-426-4411
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number2026028820
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: