Healthcare Provider Details

I. General information

NPI: 1912837725
Provider Name (Legal Business Name): JESSICA MARIE JOHNSON
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/22/2026
Last Update Date: 05/22/2026
Certification Date: 05/22/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9812 LOCKPORT RD
NIAGARA FALLS NY
14304-1114
US

IV. Provider business mailing address

9812 LOCKPORT RD
NIAGARA FALLS NY
14304-1114
US

V. Phone/Fax

Practice location:
  • Phone: 716-297-1478
  • Fax:
Mailing address:
  • Phone: 716-297-1478
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number598901
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: