Healthcare Provider Details

I. General information

NPI: 1609569714
Provider Name (Legal Business Name): JACQUELYN STELLA JOHNSON FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/02/2023
Last Update Date: 12/04/2025
Certification Date: 12/04/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3305 GASTON AVE
DALLAS TX
75246-2014
US

IV. Provider business mailing address

8501 FM 407
DOUBLE OAK TX
75077-3031
US

V. Phone/Fax

Practice location:
  • Phone: 214-820-0317
  • Fax:
Mailing address:
  • Phone: 972-966-1980
  • Fax: 972-691-4937

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberF06230198
License Number StateTX
# 2
Primary TaxonomyN
Taxonomy Code163WE0003X
TaxonomyEmergency Registered Nurse
License Number948039
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: