Healthcare Provider Details

I. General information

NPI: 1235794322
Provider Name (Legal Business Name): JESSE ALEXANDER JOHNSON JR.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/05/2019
Last Update Date: 02/18/2025
Certification Date: 02/18/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

255 W LANCASTER AVE
PAOLI PA
19301-1763
US

IV. Provider business mailing address

3803 W CHESTER PIKE STE 160
NEWTOWN SQUARE PA
19073-2336
US

V. Phone/Fax

Practice location:
  • Phone: 484-565-1510
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208M00000X
TaxonomyHospitalist Physician
License NumberMD475484
License Number StatePA
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberMD475484
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: