Healthcare Provider Details

I. General information

NPI: 1760037733
Provider Name (Legal Business Name): JESSICA MICHELLE JOHNSON PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/07/2019
Last Update Date: 09/01/2020
Certification Date: 09/01/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

110A SPRINGHALL DR
GOOSE CREEK SC
29445-5335
US

IV. Provider business mailing address

1593 KENTWOOD CIR
CHARLESTON SC
29412-9383
US

V. Phone/Fax

Practice location:
  • Phone: 843-779-6444
  • Fax: 843-990-5068
Mailing address:
  • Phone: 843-834-9837
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number3179
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: