Healthcare Provider Details

I. General information

NPI: 1770094666
Provider Name (Legal Business Name): JESSICA JOHNSON CRNA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/18/2017
Last Update Date: 09/14/2023
Certification Date: 09/14/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3580 W 9000 S
WEST JORDAN UT
84088-8812
US

IV. Provider business mailing address

2221 LAKESIDE BLVD STE 600
RICHARDSON TX
75082-4416
US

V. Phone/Fax

Practice location:
  • Phone: 801-561-8888
  • Fax:
Mailing address:
  • Phone: 469-505-1634
  • Fax: 469-436-3976

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number66680743102
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: