Healthcare Provider Details

I. General information

NPI: 1811032683
Provider Name (Legal Business Name): JESSICA T JOHNSON NURSE PRACTITIONER
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/20/2007
Last Update Date: 06/21/2025
Certification Date: 06/21/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

24944 SE 43RD ST
SAMMAMISH WA
98029-5824
US

IV. Provider business mailing address

9303 176TH PL NE UNIT 2
REDMOND WA
98052-0813
US

V. Phone/Fax

Practice location:
  • Phone: 708-654-0321
  • Fax:
Mailing address:
  • Phone: 708-654-0321
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code164W00000X
TaxonomyLicensed Practical Nurse
License Number197256
License Number StateTX
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberAP61145807
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: