Healthcare Provider Details

I. General information

NPI: 1003359951
Provider Name (Legal Business Name): JACQUELINE JOHNSON AGNP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/27/2016
Last Update Date: 10/13/2025
Certification Date: 10/13/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

822 RED TIP DR
ALLEN TX
75002-5023
US

IV. Provider business mailing address

3525 W HOLCOMBE BLVD
HOUSTON TX
77025-1313
US

V. Phone/Fax

Practice location:
  • Phone: 501-416-8045
  • Fax:
Mailing address:
  • Phone: 713-814-2800
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number81-4360797
License Number StateTX
# 2
Primary TaxonomyN
Taxonomy Code376K00000X
TaxonomyNurse's Aide
License Number81-4360797
License Number StateTX
# 3
Primary TaxonomyN
Taxonomy Code164X00000X
TaxonomyLicensed Vocational Nurse
License Number81-4360797
License Number StateTX
# 4
Primary TaxonomyY
Taxonomy Code363LG0600X
TaxonomyGerontology Nurse Practitioner
License NumberAP143029
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: